The chirurgical works of Percivall Pott: with his last corrections : to which are added, a short account of the life of the author, a method of curing the hydrocele by injection, and occasional notes and observations (Volume 2)

*2? . ' juC/J^u —

THE

CHIRURGICAL WORKS

OF

PERCIVALL POTT, F.R.S.

SURGEON TO ST. BARTHOLOMEW'S HOSPITAL.
WITH HIS LAST CORRECTIONS.

TO WHICH ABE ADDED,

A SHORT ACCOUNT OF THE LIFE OF THE AUTHOR,

A METHOD OP

CURING THE HYDROCELE BY INJECTION,

AND OCCASIONAL

NOTES AND OBSERVATIONS.

BY

SIR JAMES EARLE, F. R. S.

SDKGEON EXTRAORDINARY TO THE KING, &C.

A certis potius et exploratis petendum esse presidium; id est, his quae Experientia in ipsis
curauonibus docuent ; sicut inceetens omnibus artibus : nam ne agricolam quidem aut euberna-
torem disputatione, sed usu fieri. A. CORN. CELSU&

FIRST AMERICAN, FROM THE LAST LONDON EDITION
. IN TWO VOLUMES.

VOL. II.
PHILADELPHIA:

PUBLISHED BY JAMES WEBSTER, NO. 24, SOUTH EIGHTH STREET.

William Brown, Printer.

1819.

CONTENTS OF VOL. II.

Page.
A TREATISE on the Hydrocele, or Watery Rupture, and other Diseases

of the Testicle, its Coats and Vessels .---.- 1
Distinction between true and false Herniae ..... 5

Of the Hydrocele in general 7

Anatomical Structure of the Parts concerned 11

Anasarcous Tumor of the Scrotum 23

Distinction of the Three Sorts of Hydrocele of the Cells of the Tunica

Communis 31

The Encysted Hydrocele of the Tunica Communis .... 42

Hydrocele of the Tunica Vaginalis Testis 51

Method of Palliative Cure of the Hydrocele of the Tunica Vaginalis

Testis 69

Means for a radical Cure of the Hydrocele of the Tunica Vaginalis - 77

The Hematocele, or Tumor from Blood 94

Hydrocele in the Sac of a Hernia 110

The Pueumatocele, Varicocele, Circocele, Sarcocele, and Hydrosar-

cocele 114

The Sarcocele, or Diseased Testicle - 117

An Account of the Method of obtaining a Perfect or Radical Cure of the

Hydrocele, by Means of a Seton 171

Radical Cure of the Hydrocele, by Means of an Injection, by the Editor 189

Of the Fistula in Jino 197

The Forms under which it makes its Appearance, &c. ... 205

Habits most liable to the Disorder 208

Manner of Treating it in its Different States and Circumstances - - 214

Remarks on the Cataract 265

Remarks on the Polypus of the Nose 283

Cancer Scroti 291

Observations on the Mortification of the Toes and Feet ... 297
Remarks on the Necessity and Propriety of imputation in Certain Cases 305

Remarks on the Palsy of the Lower Limbs 325

Further Remarks on the Useless State of the Lower Limbs, in Conse-
quence of a Curvature of the Spine 345

Account of Tumors which rendered the Bones soft .... 387
Account of a Hernia of the Urinary Bladder, including a Stone - - 395
Observations on Hemorrhoidal Excrescences, by the Editor - - 401
General Index 413

A TREATISE

ON
OR

WATERY RUPTURE,

AND

OTHER DISEASES

OF THE

TESTICLE, ITS COATS, AND VESSELS.

ILLUSTRATED WITH CASES.

VOL. II.

PREFACE

SECOND EDITION

The following tract, as the title expresses, is designed
as a supplement to one published a few years ago; one
of the objections to which was, that it was defective in
matter, and ought to have comprehended the false her-
niae; they being as real diseases, and requiring chirurgi-
cal assistance as much as the true.

This deficiency I have now endeavoured to supply in
the best manner I am able.

When I began # to put these papers in order, I did not
think they would have run to such a length; and, when
they were finished, I did not know how to shorten them
without rendering them less explicit.

I am perfectly sensible that some parts of them will
appear prolix and diffuse, and that such manner of writ-
ing is in general very justly objected to; but yet cannot
help thinking that sometimes it may be excusable, or
even necessary.

When application is made to the judgment merely,
and information is intended to be conveyed to many
people of different capacities, it may become necessary
to set the same object in several different lights; and to
repeat the same thoughts many times in different words-

PREFACE.

to those who have not been much conversant with the
thing treated of, a studied brevity would become a per-
plexing obscurity. However satisfied such readers
might be with the style of the writer, they would not be
made sufficiently acquainted with the subject: they
might be pleased, but they would not be informed.

I should indeed be very sorry to have conveyed my
meaning in such manner as to disgust the judicious;
but, as my principal intention was to instruct the un-
knowing, my chief aim has been perspicuity. If the
learned and critical are not displeased, I shall be glad;
if the ignorant gain any knowledge, I shall be much
more so. The character of an elegant writer I make
no pretension to; that of a skilful surgeon, and of a
man who has done some good in the way of his profes-
sion, I should be extremely glad to deserve.

With regard to this second edition, all I have to say
is, that it has cost me some time and trouble; that it con-
tains many additions to the former; and, that I hope the
reader will find it, not only a more correct, but a more
instructive book.

TREATISE

HYDROCELE, &c.

SECT. I.

The various diseases comprehended under the general tern.
hernia, have, by surgeons, been divided into two classes; one
of which they have distinguished by tbe epithet true, the other
they have called false, or spurious.

Under the first, they have ranged all those tumors which are
produced, either by the descent, or protrusion, of some of those
parts which should naturally be contained within the cavity of
the abdomen; but which, by being displaced from their proper
situation, form swellings in the navel, groin, belly, scrotum, and
thigh.

By the second, they mean all such diseases of the testicles, their
coats, and vessels, as proceed from, or are accompanied by, the
induration, enlargement, or other morbid affection of such parts;
or occasion the lodgement, or accumulation, of extravasated fluid
within them.

So that what are generally called true hernia are tumors, occa-
sioned by the removal of certain parts from their proper and natural
situation, such parts still remaining, in general, sound, and free
from disease; while those termed false are original disorders of

» A TREATISE ON THE HYDROCELE.

the parts themselves in which they are seated: a distinction which
k invariably true, and very necessary to be attended to, by all
who would understand the real nature of each. A part of the
intestinal canal, or of the omentum, the stomach, uterus, or blad-
der, arc what most frequently make the contents of the former;
a varicous distention of the spermatic vessels, extravasated blood
or water within the membranes cither of the testicle or of the
spermatic vessels, an inflammatory enlargement, and a scirrhous
or cancerous stale of the testis itself, constitutes the latter.

The true hernia receive their distinguishing appellations, cither
from the particular part of the body in which the swelling makes
its appearance, or from what is contained within such tumor; and
are therefore called inguinal, scrotal, umbilical, and ventral; or
intestinal and omental ruptures. The spurious derive their names
either from their supposed contents, as the pneumatocele, hcemato-
cele, and hydrocele; or from the alteration made by the disease in
the natural structure of the parts concerned, as the varicocele,
cirsocelc, and sarcocele: to which some have added that inflamma-
tory defluxion on the testicle, commonly called hernia humor alis.
The pneumatocele is a mistake; there is no tumor of this kind,
and in this situation, in a living animal. It is indeed particularly
described by many writers, both ancient and modern, and said to
be a disorder to which infants arc particularly liable: but the
complaint so described, and which nurses and ignorant people do
still call a wind-rupture, is not what they take it for; neither is it
produced by wind: it is either a true intestinal hernia, or a species
of hydrocele; which will be taken notice of hereafter. The
varicocele (which is an enlargement and distention of the blood-
vessels of the scrotum) is very seldom ah original' disease, inde-
pendent of any other; and when it is, is hardly an object of sur-
gery.

The circocele, or varicous state of the spermatic vein though it
be really a disease, and sometimes very troublesome to those who
are afflicted with it, yet is seldom capable of much relief beyond
that of a suspensory bandage.

I TREATISE ON THE HYDROCELE.

SECT. II.

OF THE HYDROCELE IN GENERAL.

The term hydrocele, if used in a literal sense, means any tumor
produced by water; but surgeons have always confined it to those
which possess either the membranes of the scrotum, or the coats of
the testicle, and its vessels.

The first of these, viz. that which has its seat in the mem-
branes of the scrotum, is common to the whole bag, and to all the
cellular substance which loosely envelopes both the testes. It is,
strictly speaking, only a symptom of a disease, in which the whole
habit is most frequently more or less concerned, and very seldom
affects this part only. a The latter, or those which occupy the
coats immediately investing the testicle and its vessels, are abso-
lutely local, very seldom affect the common membrane of the
scrotum, generally attack one side only, and are frequently found
in persons who are perfectly free from ail other complaints.

Notwithstanding the obvious and material difference between
the two kinds of disease, they have by the majority of writers
been confounded together; have been considered as springing from
the same immediate source; and as requiring the same kind of
treatment; although the one is plainly and evidently a mere symp-
tom or attendant on a general disorder; and the others are strict-
ly and absolutely local complaints. This one fundamental error
has been the occasion of many others. The supposition that all
collections found in the membranes and coats of the scrotum and
testicles are of the same general kind, has produced an infinite
variety of wild conjectures concerning the particular and imme-
diate nature and origin of them. By some they have been attri-
buted to a particular indisposition of the liver, kidneys, or spleen;
by others, to a natural and necessary connexion between the sper-

;" I have seen a true anasarcous watery distention of the cells of the dartos
confined to one sldte of the scrotum onlv

8 A TREATISE OIS THE Hi'UROCELE.

Diatic vessels and (hose of the kidney; by many, the fluid has
been thought to be of the urinary kind, or at least that it ought to
have passed through the kidney, but that mistaking its right way,
it gets into the membranes of the scrotum and testicles ; b while
others have affirmed, that all complaints of this kind are really
symptoms of a dropsical habit; that the fluid comes from the
cavity of the belly, and cither passes through the peritoneum, or
extends that membrane down into the scrotum. Many cautions
have been laid down against attempting the cure of one species of
this disease hastily, or without a previous course of medicine,
upon a supposition that the defluxion is of a noxious nature; and
that, by falling on this part, it frees the constitution from several

b "Supervenlt quandoque ex causa aliqua externa et manifesta, ut ictu,
"casu, &.c. Crehro vero, ex latenle, et non manifesta. Quae ab externa
" causa accessit, aut dextrum, aut sinistrum renem indifferenter arfligit ; a la-
" tente vero, et non manifesta causa originem ducens, nunquam alium quam
" sinistrum."

ScHEJJKIl/S, OBS.

" Rene, hec malo affecto, nee officio suo probe fungente, urinx pars quam
" emulgens hxc ad se pertraxit, cum ad vesicam per male affectum renem
"non potest descendere, per seminalum in erytlnoideam delabitur ; hoc mo-
"do hydrocelem ingenerens.

"Ilinc apparet et abunde manifestum est, quam ob rem hydrocele baud ab
•' externa, sed a lalente originem ducens, non nisi in sinistram membranam
" incidat ; et hujus testem affligat."

ScHENKIUS.

" Hernia aquosa, si a causa interna et latente originem ducit, ut plurimum
" sinistram partem scroti occupat ; serosusque ille burner, in membrana tes-
" tern involvente, erythroiden dicta, colligitur : idque fit prsecipue, rene si-
" nistro male affecto ; quapropter serosus humores non attrahens, et ad vesi-
" cam non mittens, per venam seminarian), qnx in isto latere, ex emulgente
" procedit, in membranam erytbroiden delabitur."

Gul. Fab. Hildanus.

" Ne serosus humor qui a rene attrahi non potest in abdomine retirfeatur."

HlLDANUS.

" Si hernia fiat ex humoribus venientibus a renibus ad testiculum, cognos-
" citur tactu."

Lanfranc.
c " Colligitur liquor in hypochondriis, qui facile descendit."

Fab. ab AauAPEND.
" Aliquando descendit aqua illuc sicut descendit in hydropicis."

Lanfran c

A TREATISE ON THE HYDROCELE. i»

other distempers. d It has been described, as frequently pro-
ducing a corrupted or otherwise diseased testicle;* 5 as being nearly
allied in nature to those tumors which are called encysted, whose
tunics are formed out of the common membrane by mere pressure,
and as being generally accompanied with a true hernia, or de-
scent of the intestine or omentum; which last (supposed) circum-
stance has been gravely urged as a reason for not attempting a
radical cure/ The same wanton liberty has been taken, in assign-

* " Sacpe ego vidi multos per hernias liberatos esse a gravibus affectibus ;

"ab empyemate, hydrope pulmonis, &.c. unde si penitus sanetur, poterit

" multos morbos postea inferre."

Fallopius.

e " Testis autem substantia, ab acrimonia humoris, successa tempoiis cor-

" rumpitur."

SclIEN'KlUS.

" Sciendum est, quod in hernia ilia, in qua continetur aqua in vagina testis,

" et quae aliquantisper sit diuturna, corruptus est testis."

Fallopius.

" Ubi paulo diutius humor iste intus relinquitur, metuendum est ne testi-

" cuius sensim, cum eolem corrumpalur, vel occalescat, atque ita scirrhum,

"vel farcocelen, vel cancrum tandem sentiat."

IIeister.

" Ne scilicet collectum in scroto scrum per acredinem paulalim contractain

"partes, internas, et cum primis testiculum, corrumpat; et noxam magis

"periculosam efficiet."

IIeister.

"Notandum vero aquam in scroto non esse diu relinquendam ne a mora

" testis corrumpatur ; vel una cum aqua adveniat hernia carnoso et caro con-

" crescat."

Fab. ab Aq.uapkndf.nte.

f The opinion of the late Mr. Cheselden on this subject is so singular, and
so little consonant to truth or nature, that I shall take the liberty to repeat
his words, lest his great character should mislead the unwary. In the last
edition of his Anatomy, p. 264, he says, " The true hernia aquosa is from the
"abdomen, which either extends the peritoneum into the scrotum, or breaks
" it ; and then forms a new membrane, which thickens as it extends, as in
" aneurisms and the atheromatous tumors' : the dropsy in the cyst (for such
•< it properly is) rarely admits of more than a palliative cure by puncture, or
" tapping, like the dropsy of the abdomen ; and this with some difficulty, be-
cause the omentum generally, and sometimes the gut, descends with it.' 5
Which is so far from being the case, that unless in the particular and very
singular instance of a combination of an hydrocele with a congenial hernia it
never can happen ; the bags or sacs of an hydrocele, and of a hernia, being
in all other instances totally different; and the former never having any com-
munication with the belly.

VOL. l\ *

1U

A TREATISE ON THE HYDROCELE.

ing different seats to these disorders, as in accounting for their
origin: every part which invests, or accompanies, the spermatic
vessels, or the testicles, not only the tunica communis of the pro-
cess, and the cavity of the tunica vaginalis, (the true and real
seats of one or other of these disorders,) have been enumerated,
but several imaginary ones have been added; firm, compact mem-
branes have been split into lamellae; and cysts and coats have
been devised, which never had a real existence.

If all this was matter of mere speculation, and produced no
mischief in practice, it would be of no importance; but, in mat-
ters of physic and surgery, this seldom or never happens: errone-
ous ideas of the nature, origin, and seats of diseases, most com-
monly are followed by improper methods of treating them. In
the present case, the absurdity of the conjectures concerning these
circumstances in the disorder, is fully equalled by the methods of
cure which have been proposed and practised.

Upon a supposition that the extravasation of fluid was the con-
sequence of a dropsical habit, strong purges and powerfully diu-
retic medicines have been prescribed; actual cauteries have been
used; and ligatures and incisions made, both on the spermatic
vessels and in the groin, to hinder the descent of the water from
the cavity of the belly;* astringent liquors and ardent spirits have

e " Et cum totam evacuaveris aquam, cauteriza locum quern aperuisti ; et
" fac duo cauteria punctualia in inguina, ex ulraque parte unum, supra didy-
■' mum ; quod si noii cauterizes, aqua iterum redit. Sed cauteria redire
" materiam iterum non permiUunt."

I-axfraxc
" Et iterum redit nisi cauterizetur post perforationem."

Bauifus.
"In apertione duplex est intentio, scilicet aperire et prohibere ne rursus
? ' aqua descendat."

Fab. An AacAPEND.
'* Avicennas utitur lerrainentis candentitms in regione inguinis ut cor-
" rugatur pars, ne aqua posset descendere."

Fab. ab AatTAPEND.
" Sin autem in rene vitium non fuerit, et defluxum plane impedire volueris
'« incisionem, superiore parte scroti prope inguina, fieri expedit • J '

" quidem duplex chirurgo est scopus ; prior evacuare serosum hu morem
" terior prohibere ne de novo aqua in scrotum defluat." * '

"Et quiatota aqua in tunica ilia (nempe vaginali) continehatur it

A TREATISE ON THE HYDROCELE. 11

been injected, with a view to closing or soldering broken lym-
phatics; tedious and painful operations have been practised, for
the eradication of imaginary cysts; directions have been given to
evacuate the water at different times, lest the patient's strength
should fail, or his health suffer, by its being done too suddenly;
and the testicles being supposed to be frequently spoiled, by long
laying in the water, castration has often been performed in the
simple hydrocele.

Dr. Monro (the father) who is professor of anatomy at Edin-
burgh, and Mr. Samuel Sharp, late surgeon to Guy's hospital, are
almost the only writers who have sensibly and rationally explained
the true nature a*nd theory of these diseases: to them the profession
is greatly obliged for having thrown much light on the subject,
and for having furnished their readers with more just ideas than
any others.

SECT. III.

The spermatic vessels, like most of the contents of the abdo-
men, lie behind the peritoneum, enveloped in the common tela
cellulosa, or what used to be called the cellular appendix of the
peritoneum. The arteries, which are two, arise from the trunk
of the aorta, in the midway between the emulgent and lower
mesenteric. At their origin they are very small, and, contrary to
all the other arteries of the body, they seem rather to increase in
diameter as they descend. In their p*assage downward, they im-
part several branches to the cellular membrane which invests
them; and before they arrive at the testicles, they are divided into
four or five principal ones; one of these goes to the epididymis, the
others to the testis; the latter having passed the tunica albuginea,

"testiculus ei innataret, ne in posterum denuo descenderet aqua acu incur-
" vato ac filo reduplicato universam hanc tunicam (prxter vasa seminalia) ap-
■' prehendi et mediocriter constrinxi, atque ligavi."

Fab, Hudaituu,

12 A TREATISE ON THE HYDROCELE.

and being convoluted in a most wonderful manner, composes the
greatest part of the body of that gland: from these convolutions of
the spermatic artery, the semen is secreted: which fluid is, after
such secretion, immediately received by those particular vessels,
which late anatomists have agreed to call the vasa efTerentia.
These vary in their number, in different subjects, being from ten
to fifteen, moYe or less: when collected together they form the
globus major, or larger extremity of that body, which, from its
situation, is called epididymis: after this, they unite into one
single tube, which being convoluted and contorted, in the most
miraculous manner, constitutes the rest of that same body: so that
the whole of the epididymis, except that immediate point which
is formed by the concurrence of the vasa efTerentia, does really
consist of one single tube, whose diameter is said, in no part, to
exceed the eightieth of an inch, but which is contorted some
thousands of times; and if unravelled, and drawn out, is some
yards in length. From the lesser extremity of the epididymis
proceeds the vas deferens, or that tube through which the semen
is conveyed from the testis toward the penis; or, in other words,
when this wonderful tube ceases to be convoluted, and puts on the
appearance of one single, smooth vessel, it is then called vas de-
ferens. This arises from the lesser end of the epididymis, en-
veloped in the same common tela eellulosa, in which the spermatic
artery and vein are invested; and when it has got just above the
edge of the os pubis, it separates from the said vessels, and pass-
ing down behind the peritoneum, proceeds to the inferior part of
the neck of the bladder, where it deposits the semen, in the
receptacles appointed for that purpose, called the vesiculae se-
minales.

The blood, after the seminal secretion is performed, returns
back into the general mass, by the spermatic vein: which on the
right side empties itself into the vena cava, and on the left into the
emulgent.

While the spermatic vessels are within the cavity of the belly
the cellular membrane, in which they are enveloped, is much
more lax and tender, and is endued with larger cells, than it is on
the outside of the same cavity. As they go under the transversalis
and obliquus internus muscle, and through the obliquus externus

A TREATISE ON THE HYDROCELE. 13

they receive a considerable addition of cellular membrane from
the adjacent parts; and, when they have passed through the ten-
dinous aperture of the last named muscle, they, together with their
cellular tunic, h are covered by, and enveloped in, that expansion
of muscular -fibres, called the cremaster.

The membrane surrounding all that part of the spermatic ves-
sels, which is on the outside of the abdomen, is called the tunica
communis, or tunica vaginalis of the chord; and is (as has already
been said) merely cellular; totally void of all other cavity than its
cells; firmly adherent to the surface of the said vessels, in every
part; and plentifully furnished with lymphatics.

It is of very great importance to have a just idea of the struc-
ture of this part of the funiculus spermaticus. The old term, tu-
nica vaginalis, conveyed a very false one: it implied, that the ves-
sels were contained within it, as in a sheath, and that, if the said
vessels were not there, this coat would form an empty bag, con-
sisting of one cavity only; than which nothing can be more un-
true.*

h The passage of the spermatic vessels under two of the muscles, and
through the third, is a circumstance of much importance, and what every prac-
titioner ought to be well acquainted with.

The common doctrine is, that in each of the oblique muscles and in the
transversalis is a tendinous aperture, for the transit of the spermatic chord ,
and these supposed openings are called the rings. This is a mistake, which
even some very modern writers in anatomy have fallen into : and lest their
words should not convey an idea sufficiently erroneous, some of them have
given us drawings of all these openings in regular gradations, above and be-
hind each other. Nothing can be more false than such representation : the
spermatic vessels do never pass through, but always under the transversalis
and obliquus interims, at such distance as never to be affected by their action,
or to suffer any stricture or strangulation from them. On the contrary, the
spermatic chord always passes through an opening made for that purpose in
the tendon of the obliquus externus ; the action of which it is liable to be af-
fected by: and when it is accompanied by a portion of intestine, (as in the
case of an hernia,) it is this tendinous aperture which produces the stricture,
the symptoms, and the hazard — a circumstance of great consequence for
every man to know, who may ever be called upon to operate on a strangu-
lated hernia.

■ Even M. de la Faye, whose notes on Dion is have rendered the works of
the latter more useful, has fallen into the common mistake with regard to this
tunic, by supposing both it and the vaginalis to be formed out of the same
membrane, and allotting a cavity or bag to the former. " II faut remarquer,

14 A TREATISE ON THE HYDROCELE.

This is one great source, from whence many of the errors,
which have been committed in the description of such diseases,
as have (or are supposed to have) their seat in this part, have
sprung; and therefore I take the liberty of repeating, that this tu-
nic has no one particular cavity, but is a mere cellular membrane
throughout its whole extent; and that it terminates, in a great
measure, just above the epididymis, though a continuation of it
may be traced on the surface of the tunica vaginalis testis.

The coats of Jhe testicle are two only; viz. the tunica vaginalis,
or that bag which loosely invests it, without any adhesion to it,
except in one particular part; and the tunica albuginea, or that
membrane, which is the immediate and proper covering of its vas-
cular structure. A true and clear idea of these is absolutely ne-
cessary to the right understanding the diseases to which this gland
is subject. In order to obtain such idea, the testicles must be
examined, not only in an adult state, but in the infantine, and in
that before birth also; each of these states having its peculiarities,
end all tending to explain the true nature of such maladies, as it
is frequently subject to.

The testicles of the human species are always formed withiu
the cavity of the belly, and remain there until or very near unto
the time of birth. While they are within the abdomen, they are
covered by one coat only; which coat firmly adheres to the vascu-
lar structure of them, and is evidently derived from the perito-
neum, in the same manner as the outer coat of each of the viscera
of the said cavity is. Their situation, during the first months, is
higher than in the latter; and as the foetus increases in size, they
slip gradually lower. Within the cavity of the abdomen, on each
side, a little below the testes, is a small opening, or orifice which
leads immediately into a small but firm membranous baa- or cyst,
whose upper part, or neck, passes through the opening in the ten-
dons in the obliqui exterui muscles; while its lower part or sac-

« que la tunique vaginale et la gaine du cordon spermatique sont une con-

•'' tinuation du tissue celluleux du peritoine, qui s'allonge pour enveloper le

" testicule ; a I'endroit, ou cette continuation s'elargit, la nature a f

" cloison qui empeche la communication qui se trouveroit em™ i>;„. •
,. . * ' /. , . . '""■ cmre 'mteneurde

•' la game du cordon spermatique, et celui de la tunique vaginale "

De IA FAY*

A TREATISE ON THE HYDROCELE. 15

i-.ulus, lies on the outside of said muscles in the groin, enveloped
in the common tela cellulosa. These orifices are always open
until birth; and, most frequently, for some while after; during all
which space of time, the said sacculi have free and open com-
munication with the cavity of the belly.

By means of these orifices the testicles pass from the cavity of
the abdomen, through the tendinous apertures, into the sacculi in
the groins; but, the time in which they make this transit is by no
means certain: sometimes it is just before birth, sometimes just
after; sometimes they drop immediately into the scrotum, and
sometimes they remain a considerable time in the groins; and, it
now and then happens, that they never pass through the muscle at
all, but remain for ever within the belly. These are a kind of
lusus naturae; but, in the ordinary course, they soon pass from the
groins into the scrotal bags, the communication between the said
bags and the belly continuing open some little time longer.

When the testicles are got fairly down into the sacculi, if the
said sacculi be laid open, it will appear that the testicles arejoosclv
enveloped by them, in such a manner as to be perfectly free from
all cohesion, except in one part, where this bag and the proper
coat of the testicle (the albuginca) are so firmly united, as to be
plainly and demonstrably a continuation of one and the same mem-
brane. And, while the communication with the belly continues
free and open, if the sacculi be divided from the bottom upward,
it will as evidently appear that the membrane of which they are
composed is a continuation, or process of that part of the perito-
neum which lines the muscles of the abdomen.

Some time after birth, the necks of these sacculi become close
and impervious; and, from that time, all communication between
their cavities and that of the belly ceases. The time when this
happens is various and uncertain; I have seen them perfectly closed
within a week, and open at the end of two months; nor do they
both necessarily become close at the same time, in the same sub-
ject.

It sometimes happens, that while these passages are open, a
piece of intestine insinuates itself into one of them, and, prevent-
ing its closing, produces what Haller calls a congenial hernia; a
disease which, though a modern discovery* has always been very

16 A TREATISE ON THE HYDROCELE.

frequent. It also sometimes happens, that the spermatic vessels
not being sufficiently closed, one of the testicles rests in the groin,
just without the opening in the abdominal muscle, and, by not be-
coming pendulous in the scrotum, the orifice of the neck of the
sacculus is not closed at all; even though no portion of gut or caul
has got into it.

When these orifices have been once perfectly closed, there
never is any future communication between the cavities of the
sacculi and that of the belly; nor can any thing solid or fluid
(however small in size or quantity) ever, after this period, pass
from the one to the other. The upper part, or neck, now loses
all appearance of a distinct canal; and the lower part, or sac,
loosely invests the testicle, and its epididymis, without any adhe-
sion, except in the hinder part. The inside or cavity of this sac
is constantly kept moist by the exudation of a fine fluid; which
fluid is as constantly absorbed: so that, while these parts enjoy a
sound healthy state, the fluid is no more in quantity, than what
just serves to lubricate and keep moist the surfaces of both mem-
branes, and thereby prevent any unnatural cohesion of them with
each other.

From these premises, the following inferences, serving to point
out and explain the true nature and seat of some of the diseases in
question, may, I think, be deduced.

1. That the sacculi, or bags, found in the groins, are originally
formed parts.

2. That they are placed there for the future reception of the
testicles; and that when the upper part, or neck, of one of them
becomes close and impervious, the lower part, or sacculus con-
stitutes and forms what is properly called the tunica vaginalis
testis; which is therefore a true and original process of the peri-
toneum.

3. That of all the parts contained within the scrotum these
sacculi are the only ones which ever naturally communicate with
the cavity of the belly.

4. That, after a certain space of time, that communication
ceases.

A TREATISE ON THE HYDROCELE. 17.

■3. That whatever fluid may be shed from the spermatic ves-
sels, or collected, or extravasated, in the cells of the tunica com-
munis, or in those of the dartos; yet no part of such fluid can be
derived from, or received into, the cavity of the tunica vaginalis
testis.

G. That a total failure of the secretion of that fine fluid, which
should moisten the inside of the vaginal tunic, and the outside of
the albuginea, must be followed by an unnatural cohesion of these
membranes with each other; and either a partial or total abolition
of the cavity of the former.

7. That if more of this fluid be deposited than the absorbent
vessels can take up, or if the absorbent vessels do not execute their
office, such fluid must be accumulated within the cavity of the
said tunic; from which, there being no natural outlet, the conse-
quence must be a gradual distention and enlargement of it.

8. That the natural communication between the cavity of the
tunica vaginalis and the belly, not being shut until some space of
time after birth, it may become close at its upper part, while there
is a quantity of fluid in the lower, too large for the absorbent ves-
sels to take up immediately; and, consequently, that such infant
will, until that office be executed, labour under a true hydrocele
of the tunica vaginalis testis; a case which is very frequent, though
generally mistaken for a wind rupture.

And, 9. That the fluid of that kind of hydrocele, which is form-
ed by the sac of a congenial hernia, must be lodged within the
cavity of the vaginal coat; while all collections of serum, in the
sacs of all other kinds of hernia?, most necessarily be perfectly
distinct from the said tunic.

I should now proceed to the examination of each distinct spe-
cies of hydrocele, but will intrude upon my reader's patience
while I mention a circumstance or two, relative to the passage of
the testicle from the belly into the scrotum; and which, as a prac-
titioner, he may possibly think worth his attention.

I have said, that the time in or at which the testicles pass from
the belly, through the groin, into the scrotum, is by no means cer-
tain; that it varies in different people; that even in the same per-
son, the two testes do not always pass down at the same time;

'TiT.. rr. c

IS- A TREATISE ON THE HYDROCELE.

'hat sometimes both of them, sometimes one, remains within the
belly, or in the groin, for a considerable space of time afterbirth:
and that it now and then happens, that one or both of them never
get into the scrotum at all.

I do not know any particular inconvenience arising from the
detention of a testicle within the cavity of the belly; but the lodge-
ment of it in the groin not only renders it liable to be hurt by ac-
cidental pressure, &c. but when it is so hurt, may be the cause
of its being mistaken for a different disease, and thereby occasion
its being very improperly treated. To which considerations, this
may be added, that there is no kind of disease, to which the tes-
ticle is liable in its natural situation, but what may also affect it.
in any or all its unnatural ones.

CASE I.

I was sent to, in a great hurry, from the neighbourhood of Lime-
house, and desired to bring with me whatever I might want for
the operation of a bubonocele. I found a young, healthy, sea-
faring man, lying across his bed, and complaining of most acute
pain in his groin and back. He told me, that, "In the forenoon
of the day before, being at work on board his own vessel, he fell,
and struck his groin against a piece of timber with great violence;
that it gave him such exquisite pain, that he fainted away; that
his groin became immediately swollen to a very considerable de-
gree; that as soon as he could get home, he applied to his apothe-
cary, who bled him, put him to bed, and poulticed the tumor; that
he passed the night without sleep, and in great agony; that when
his apothecary came to him the next morning, he (the patient) in-
formed him of a circumstance, which, in his confusion he had
forgot the night before, viz. that he had long had a rupture on
that side, which had never been perfectly returned- that upon
receipt of this information, the apothecary had bled him a^ain
and had taken some pains to return the rupture: but finding that
he made no progress, and that his attempts produced great in-
crease of pain, he had desisted, and had given him two clysters
*nd a purge; neither of which occasioning such discharge as he

A TREATISE ON THE HYDROCELE. 19

expected, and a kind of blackness now beginning to appear on the
part, he desired immediate assistance." By the time this acr.
count was finished, the apothecary came in, and confirmed it.

The pain was exquisite; and while I was asking the patient a
few questions, he became very sick, and vomited. The groin
and scrotum were much swelled, and very hard; but the general
figure and appearance of the tumor did not appear to me like that
of a bubonocele: instead of pointing obliquely from the ileum to-
ward the pubes, it lay, as it were, across the groin: the scrotum
was full and large; but I thought it felt much harder than I had
ever found a piece of intestine do; and with regard to the altera-
tion of colour, I cannot say it gave me much uneasiness; for it
was not at all like the effect of mortification, but had all the ap-
pearance of an extravasation, or ecchymosis. On the other hand,
the man had not had a fair stool for three days; he had been very
sick, and had vomited; his belly was tight, hard, and painful; and
his pulse much too quick. From examination of the tumor, I
could get very little information; for the pain was so exquisite,
that he could not bear the slightest touch: however, from what
examination I could make, it appeared to me, that if this was an
intestinal hernia, it was such an one as Iliad never yet met with;
and nothing but the circumstance of his having worn a truss for-
merly, by the direction of a surgeon of character, could have in-
duced me to have entertained such suspicion. I inquired again
concerning this rupture, and was told, that he had worn a truss
for it the first four years of his infancy, but that it never kept the
gut totally or perfectly up; and that, as he grew bigger, and ran
about, he was obliged to leave it off, on account of the pain it
gave him: that since he had left it off, he had not observed any,
or very little alteration in the tumor; (none in its situation, though
a little in its size;) and that it had never given him any trouble or
uneasiness, if he did not handle it, or kept the waistband of his
breeches and his watch from pressing it. All this was far from
being satisfactory: and as the present state of the parts was such,
as was by no means favourable fbr an operation, I determined,
previous to any other attempt, to try what a brisk cathartic would
produce. A stimulating clyster was immediately thrown up, and
a solution of an ounce and a half of Glauber's salts in two ounces

20 A TREATISE ON THE HVDROCELE.

of inf. sense swallowed, which, in little more than an hour, pro-
duced so plentiful a discharge, that the belly became soft and
easy, and we were perfectly free from all apprehensions of a stric-
ture. Fomentation, poultice, &c. were frequently applied to the
tumor, which in three or four days began to subside; and in about
seven or eight the scrotum was so unloaded as to permit easy and
accurate examination; by which means wc were satisfied, that it
contained no testicle. Upon mentioning this circumstance to the
patient, he said that he never had one on that side. This declara-
tion was a solution of all difficulties, and of all the appearances.
When all the effects of the blow were removed, there appeared
in the groin, just on this side of the opening in the abdominal ten-
don, a testicle of natural size and figure; which testicle, by being
much bruised, had caused all the mischief.

CASE II.

A poor man came to St. Bartholomew's hospital, and desired
assistance for a swelling in his groin; for which he had, for a
month before, been taking Jesuits' drops and other quack medi-
cines, till he had not a farthing left. Upon removing an adhesive
plaster, I found a tumor which was large and painful; but at the
same time so moveable, as to be very unlike any affection of the
inguinal glands. The account which the man gave was, that
' He had always had a lump in that groin, and never any testicle
on that side; that when young, he had worn a truss for it, upon a
supposition of its being a rupture; that when he came to work for
his living, he could no longer bear the uneasiness which the truss
gave him, and therefore had left it off for years: that since that
time he had never perceived any material alteration in the tumor,
nor had it ever given him any trouble, till he had got a clap about
two months before; upon the sudden disappearance of which the
lump in his groin became large and painful."

In short, the man had got a hernia humoralis of the testicle in
his groin; which, by means of proper treatment, bleeding, cata-
plasm, and rest, be soon got well of.

A TREATISE ON THE HYDROCELE. 21

CASE" III.

A middle-aged man came to St. Bartholomew's, for advice for
a tumor in his groin.

He was apparently in good health; the tumor was of an oval or
egg-like form, indolent when not pressed, perfectly moveable, lay
just in the groin, and had by more than one person been mistaken
both for bubo and bubonocele. When handled or pressed rudely
in consequence of the latter opinion, it was painful for some hours
after; and the pains (to use his own words) always shot up into
his back. It was on the left side; on which side there was no
testicle in the scrotum, nor had there ever been one; but on the
right side every thing was as it should be. He said that within
two years it had been considerably enlarged; and that it now was
become very troublesome to him.

It appeared very plainly to me that the tumor was caused by the
left testicle; which testicle was in a diseased stale, but very fit for
and very capable of extirpation. I advised the man to submit to
the operation, and he had complied; but the late Mr. Griffiths
(one of our then assistants) coming into the ward, I desired him
to look at the case. Whether he did not attend to all the cir
cumstances, or for what other reason, I know not; but he took it
into his head, that it was a tumor of another kind, that might be
removed by internal medicine; and dissuaded the man from un-
dergoing what I had proposed: upon which I did not take him into
the hospital.

Some months after, the swelling becoming larger and more
troublesome, he applied to St. George's hospital. The gentlemen
there gave him the same opinion, and the same advice which I
had given him; he submitted, and got a cure, by the removal of a
testicle which had never been lower than his groin, and which
was now become scirrhous

22 A TREATISE ON THE HYDROCELE-

CASE IV.

The late Mr. Hoi ling worth desired me to go with him to see a
patient in the neighbourhood of Clerkenwell. It was a man about
fifty-five years old, who had a large ulcerated cancerous tumor in
his right groin, with high callous edges: it always discharged a
large quantity of a most offensive gleet; at times it bled profusely,
and was always extremely painful.

The patient said, that when first it became troublesome, he had
showed it to two eminent rupture -eurers; one of whom said, that
it was a piece of caul, and offered, for twenty guineas, to cure him
by cutting it out: the other (more modest, or less hardy,) only
sold him two bandages for it; neither of which he could ever
wear.

When Mr. Hollingworlh carried me to see it, it had just been
left by a*ancer-curer, who had applied to it an escharotic; and
which, by the patient's account, as well as by the appearance of
the sore, had made terrible havoc.

During all this time, no one who had seen him (and what is
still more remarkable, not even the patient himself) had remarked,
that in that side of the scrotum he had no testicle.

The state, both of the man and of the sore, forbad any chirur-
gical process; and my advice to him was to dress the sore lightly,
and have recourse to tinct. thebaic, for ease: which advice he fol-
lowed, during the short remainder of his life.

When dead we examined him, and found that the disease con-
sisted in a cancerous testicle lying in the groin; the spermatic
vessels of which were varicose, and knotty all the way up to the
kidney, having here and there a bladder of yellow serum in the
cellular membrane: the lymphatic glands about the vertebrseof'
the loins were diseased, as was the liver; and on the surface of
the right kidney was a collection of offensive sanies.

A TREATISE ON THE HYDROCELE.

SECT IV.

THE ANASARCOUS TUMOR OF THE SCROTUM.

The scrotum is the common receptacle of both the testicles, and
consists of the cuticula, cutis, and what all the anatomists have
now agreed to call the dartos; which is a loose cellular membrane,
perfectly void of fat, and whose cells or cavities communicate
with each other, with the utmost freedom, through every part.

As this membrane has no immediate communication fvith the
cavity of the abdomen within the peritoneum, it is plain, that
whatever kind or quantity of fluid may be deposited in it, it cannot
be derived from the said cavity, even though the patient should
labour under a true ascites; but as its cells have a free intercourse
with those of the general cellular membrane all over the body,
they will be liable to be affected by all those disorders which
have their seat in that membrane; that is, by all disorders pro-
ceeding from a low impoverished state of blood, from a deficiency
of the urinary secretion, or from non-execution of the office of the.
absorbent vessels; and consequently, in anasarcous and leuco-
phlegmatic habits, will become the seat of a watery extravasation.

This watery swelling of the scrotum, although it be most fre-
quently a symptom of a dropsical habit, and very often accompa-
nies both the general anasarca, and the particular collection with-
in the abdomen, called the ascites, yet, even in the latter case,
neither is, nor can be, derived from the cavity of the belly, but is
confined to the tela cellulosa, which lies on the outside of the peri-
toneum: the water derived from hence distends the scrotum, in the
same manner, and for the same reasons, that it often docs the legs
and feet. The cells of the dartos being larger and absolutely
void of fat, and the skin which covers them being extremely
dilatable, and giving way for a larger influx into this part than into
most others, has indeed occasioned iis being taken notice of as a
particular disease, though it is most properly a symptom only.

This being the case, and the true method of cure consisting in

24 A TREATISE ON THE HYDROCELE.

an internal medical process, it has been, I think, improperly rank-
ed among the species of hydrocele; though the nature of the con-
tents will certainly admit the use of the word.

It is indeed a disease, which properly belongs to the physicians;
but as it is of some consequence to be able to distinguish it from
other disorders affecting the same, or the neighbouring parts, and
as surgeons are often called upon to assist in alleviating some of
the inconveniences which this defluxion produces, it cannot be
amiss in this place to give a short account of it, and of the most
proper chirurgical method of attempting its relief.

It is an equal, soft tumor, possessing every part of the cellular
membrane, in which both the testicles are enveloped, and con-
sequently is generally as large on one side as on the other; it
leaves the skin of its natural colour; or, to speak more properly,
it does not redden or inflame it. If the quantity of water be not
large, nor the distention great, the skin preserves some degree of
rugosity; the tumor has a doughy kind of feel; easily receives,
and for a while retains, the impression of the fingers; the raphe or
seam of the scrotum divides the swelling nearly equally; the sper-
matic process is perfectly free, and of its natural size; and the
testicles seem to be in the middle of the loaded membrane. This
is the appearance when the disease is in a moderate degree. But
if the quantity of extravasated serum be large, or the disease far-
ther advanced, the skin, instead of being wrinkled, is smooth,
tense, and plainly shows the limpid state of the fluid underneath:
it is cold to the touch, does not so long retain the impression of
the finger, and is always accompanied with a similar distention
of the skin of the penis; the preputium of which is sometimes so
enlarged, and so twisted, and distorted, as to make a very disa-
greeable appearance. These are the local symptoms: to which it
may be added, that a yellow countenance, a loss of appetite a
deficiency of urinary secretion, swelled legs, a hard belly, and
mucous stools, are its very frequent companions.

The cure of the original disease comes, as I have already said,
within the province of the physician, and requires a course of inter-
nal medicine: but sometimes the loaded scrotum and «*«;,

viuu, aim penis are so

troublesome to the patient, and in such danger of mortifi t'
that a reduction of their size becomes absolutely necps. sary . a a I

A TREATISE ON THE HYDROCELE. 2o

other times a derivation, or discharge, of the redundant cxtravasat-
ed serum from this part is ordered as an assistant to the internal
regimen.

The chirurgical means in use for this end is called in general
scarification; a term, whose precise sense has by no means been
settled; by which it has now and then happened, that a general
order being given, and the particular method of executing it being
left to the choice of those who have not been sufficiently acquaint-
ed with this kind of business, much hazard has been incurred,
and considerable mischief done, which might have been avoided.

The means of making this discharge are two, viz. puncture and
incision: the former is made with the point of a lancet; the latter
with the same instrument, or with a knife.

The generality of writers on this subject have spoken on the
two methods in such a manner, that a practitioner, who had seen
but little of either, would be inclined to think that it was a matter
of great indifference which we should make use of, and that the
safety and utility of each were equal, which is by no means the
case.

The intention of the use of either is, by a discharge of extrava-
sated serum, to alleviate the present uneasiness; and, by reducing
the size of the scrotum, to render it less troublesome, and less likely
to mortify. In some few instances it has indeed happened, that
this drain has proved a radical cure of the original disease; but
that has been accidental, and is not in general to be expected.
The intention is generally palliative; and, if the patient lives, is
most likely to require repetition: therefore, if there be any differ-
ence between the two methods, with regard either to ease or
safety, there can be no doubt which ought to be preferred.

All wounds of membranous parts, in anasarcous or dropsical
habits, are necessarily both painful and hazardous: they are apt to
inflame, are very difficultly brought to suppuration, and will often
prove gangrenous in spite of all endeavours to the contrary. But,
the larger and deeper the wounds are, the more probable are these
bad consequences. Simple punctures with the point of a lancet,
are much less liable to be attended by them, than any other kind
of wound; they generally leave the skin easy, soft, cool, unin-

vol. ii. n

26 A TREATISE OS THE HYDROCELE.

flamed, and in a state to admit a repetition of the same operation,
if necessary. Incisions create a painful, crude, hazardous sore,
requiring constant care. Punctures seldom produce any uneasi-
ness at all; and stand in need of only a superficial pledget, for
dressing.

Now, although there is so very material a difference in the
symptoms and trouble attending the two methods, yet there is none
in their effect: the communication of the cells of the dartos with
each other is so free, through every part of it, that punctures made
with the fine point of a bleeding lancet, into the most superficial
of them, will, as certainly and as freely, drain off all the water, as
a large incision, without any of its inconveniences or its hazard.
Neilher the one nor the other will cure the original disease, unless
by mere accident: they are both made with a design to cure only
the local one. The same habit and constitution remaining, the
same effect will in general follow, and the same relief be again
necessary. The ease, the freedom from bad symptoms, or from
danger, and the state in which the parts are left, render one method
practicable at all times, and capable of being repeated as often as
may be thought necessary: the fatigue, pain, confinement, and ha-
zard, which most frequently attend the other, make one experiment
in general as much as most people choose to submit to, or indeed
an opportunity of complying with.

CASE V.

A man, about fifty-five years old, who had lived freely, was
afflicted wtth an anasarcous tumor of the belly, legs, thighs scro-
tum, and penis, accompanied with the general symptoms which
most frequently attend such complaints, viz. prostration of appe-
tite; little urine, and that high coloured; a hard belly; and a
bloated face.

He had taken many medicines bj'the direction of a physician
in the country, and more than one quack remedy since he had
been in London, but to no purpose: the watery load increased
daily, and the swelling of the penis and scrotum became so trou-
blesome, as to prevent his wearing breeches

A TREATISE ON THE HYDROCELE. 27

In these circumstances, a person who attended him in the ca-
pacities of apothecary and surgeon, proposed to draw off the water
by an incision on each side of the scrotum; to which the patient
consented. The incisions were made, and in a few hours the
scrotum was empty and flaccid.

At the distance of five days from this operation, his surgeon
died, and I was desired to visit him.

I found him in bed, with a painful, foul, undigested sore, on each
side of the scrotum; which, though it had at first been emptied by
the incision, was now again considerably loaded with serum, but
at the same time hard and inflamed: the edges of the wounds were
livid, the discharge from them was a discoloured gleet; and the
pain was so great, that the man could get no rest; his pulse was
frequent, hard, and small; his breathing not perfectly free; his
urine little, and high coloured; his thirst very troublesome; his
belly hard and tight; and, having taken an opiate every night from
the time of the operation, he had not had a stool for three days
past.

1 dressed the incisions with a soft digestive; and, covering the
whole scrotum with a warm poultice, tied it up in a bag truss; di-
rected a clyster to be thrown up immediately, and a purge to be
taken the next morning: from which in the following day he had
four or five stools, and by which his respiration was relieved, and
his belly rendered softer.

Next day the inflammatory hardness of the scrotum seemed to
be going off, but to be succeeded by an emphysematous kind of
tumefaction; and, in four days from that of my first visit to him,
the whole bag was in a state of mortification, notwithstanding the
constant use of fomentation, cataplasm, &c.

Having already taken a large quantity of medicine of different
kinds, it was with much difficulty that I could prevail on him to
hear of any more: but, upon making a true representation to him
of the state of his case, and of his imminent hazard, he consented
to take the bark, with some confect. cardiac, and tinct. rad. ser-
pent, every three or four hours.

By putting a tea-spoonful of brandy into each dose, it kept upon
his stomach. At the end of three days, the pain and soreness
were considerably lessened; and on the sixth he got a little quiet

28 A TREATISE OS THE HYDROCELE.

sleep without any opiate: on the ninth, the mortified parts seemed
inclined to suppurate, and the gleet was small, in comparison of
what it had been; on the twelfth, there was an appearance of tole-
rable good matter from the edges; on the fifteenth, a laudable sup-
puration was established, and the mortified parts were every where
loose and falling off. Instead of a small quantity of high coloured
urine, he now made what was nearly equal to his drink, and that
very well conditioned; and the watery extravasation in his legs and
thighs was Considerably diminished.

He now began to nauseate the bark, in the form in which he
had hitherto taken it; it was therefore changed for another, which
he took at larger intervals; and, to assist his urinary discharge, his
apothecary gave him an infusion of the cineres genistas and horse-
radish, which answered the purpose very well.

The whole scrotum and dartos cast off in a large slough, and
left the tunica vaginalis of both testicles as bare and clean as if
they had been dissected: these were soon covered by an incarna-
tion, which supplied the place of the scrotum tolerably well; and,
by persisting in the use of the same remedies for a few weeks
longer, he was restored to perfect health.

CASE VI.

A man, not exceeding forty, who had drunk freely of spirituous
liquors, was thereby brought into the same circumstances as the
patient in the preceding case; that is, his countenance was yellow
and bloated; his legs, thighs, scrotum, and penis, loaded with
a watery tumor; he had little or no appetite; and made a very
small quantity of high coloured urine.

Internal remedies having been ineffectually tried for some time
he was advised to have an incision made on each side of the
scrotum; by means of which, all the swelling, both of it and of
the penis, was immediately removed, and the patient much
pleased.

On the fourth day from the operation all discharge of serum
ceased, and the wounded part swelled, inflamed, and became very
painful. Fomentation, cataplasm, and proper digestive dressings

A TREATISE ON THE HYDROCELE. 29

were used, but without any relief from the pain, or any beneficial
alteration in the appearance of the sores. On the sixth day from
that of the incision, I was desired to meet the gentleman that had
the care of him. I found that the hard inflammatory swelling,
which a day or two before had occupied the whole scrotum, was
now gone off, and that it was become flabby and livid, especially
about the incisions.

I proposed his taking the cortex, but it was not complied with;
nor do I know what the medicines were which he did take,
neither myself nor his attendant surgeon being consulted on that
head. Warm spirituous fomentations, with proper poultice and
dressings, were continued, but to no purpose. I saw the patient
each morning for four days; duuing which, he got little or no rest,
and complained of great pain and burning heat within his belly;
the watery extravasation in his thighs and legs increased daily;
the whole scrotum and skin of the penis became black, and mor-
tified, as did also the part of the pubes; and on the eleventh day
from that on which the .incision was made, he died.

CASE VII.

A man, about forty-five years old, by name Corby, who was a
patient in St. Bartholomew's hospital on another account, showed
me a swelling on the left side of his scrotum. It was large, full, tight,
and had all the symptoms and appearances of an hydrocele of the
tunica vaginalis; viz. the fluctuation of the fluid, the freedom of the
upper part of the process, and the concealment of the testicle. I
thought myself so clear in the true nature of the disease, that, without
any scruple, I pierced it with a small trocar in the lower and an-
terior part, and thereby let out about two ounces of limpid water;
but could by no means draw off any more, though I pressed a
probe up through the cannula, and used every other means proper
to obtain it.

I withdrew the cannula, and examined the swelling again,
which was but little diminished by what had been done: but,
though it was not much decreased in size, it was considerably
altered in appearance. I could now very plainly distinguish the

30 A TREATISE ON THE HYDROCELE.

testicle, and was convinced, that the whole disease was confined
to the cells of the dartos. In short, it was (what I had never
seen before) an anasarca of that membrane, on one side only;
having a certain quantity of the water in one cyst or bag, and the
rest diffused through the cells in the usual manner: the latter made
all the tumefaction which remained after tapping; and the former
had concealed the testicle.

Being now truly satisfied of the nature of the case, I made an
incision, about an inch long, through the scrotum into the loaded
dartos; intending thereby to drain off the water, and, by pro-
curing a suppuration, to cure the disease. Into the incision I put
a little dry lint, and tied the scrotum up in a bag-truss.

To my great astonishment, the. next day my dresser told me,
that Corby's scrotum was swelled to a great size, and that the in-
cision was already livid. I went to the hospital and found it so: I
ordered the (>art to be fomented, and wrapped up in a warm poul-
tice; and that the man should take the cortex freely, till the phy-
sician should see him.

In three days time, the whole scrotum and the skin of the penis
were completely mortified; and a considerable part of the pubes
altered and vesicated: his pulse was quick and small; he com-
plained of a burning heat in iiis belly and bladder; his thirst was
intense; and his extremities cold.

For several days I was convinced that each would be his last:
his fomentation, cataplasm, and dressings, were continued. The
doctor ordered him a dram of the bark, as often as his stomach
would bear or keep it, in a julep, well impregnated with volatile
salt; and the poor man earnestly begged to be allowed a pint of
porter a day; which he had. At last, in about three weeks time,
the whole scrotum, the integuments of the penis, and some part of
the pubes cast off, leaving the corpora cavernosa and the tunica va-
ginalis as clean as if they had been dissected. The man eot well

More of the same kind of cases might be produced, in which
the trouble and hazard attending large incisions of the scrotum in
dropsical cases, have been great; but the similarity of them ren-
ders it unnecessary. I shall therefore only add, that from the
simple puncture I have seldom met with either; and that I have

A TREATISE ON THE HYDROCELE. 31

as seldom known them fail to answer the purpose for which they
were intended, viz. a temporary discharge of serum from the cel-
lular membrane.

SECT. V.

If we consider the preceding complaint as merely symptomatic,
and do not rank it among the different kinds of hydrocele, there
will then remain only three; viz.

1. That which consists of a collection of water in the cells of
the tunica communis, or cellular emembrane, enveloping and con-
necting the spermatic vessels.

2. That which is formed by the extravasation of a fluid, in the
same coat as the former, but which, instead of being diffused
through the general cellular structure of it, is confined to one
cavity or cyst, in which all the water constituting this species of
disease is contained; the rest of the membrane being in its natural
state.

3. That which is produced by the accumulation of a quantity
of water, in the cavity of the tunica vaginalis testis.

These three are distinct, local, and truly within the province
of surgery. They may accidentally be combined or connected
with other disorders, but not necessarily; and are frequently found
in persons whose general habit is good, and who are perfectly free
from all other complaints.

THE HYDROCELE OF THE CELLS OF THE TUNICA COMMUNIS.

In the anatomical account of the parts, which make the seats
of the different kinds of hydrocele, it has been observed that the
spermatic vessels, from their origin quite down to the insertion
into the testicle, are enveloped in, and connected together by, a
membrane, called formerly tunica vaginalis vasorum spermatico-
mm,but now (more properly) tunica communis. That this mem-

A TREATISE ON THE HYDROCELE-

brane so enveloping the spermatic vessels has no one particular
cavity (as its old name would seem to imply); but is merely
cellular, as either the inflation of air, or the extravasation of a
fluid, will always prove. That while it is within the cavity ol
the belly, its cells are lax and large; and when it has passed out
from thence, and has formed a part of the spermatic process, by
enveloping its vessels, its cells are rather smaller, and the mem-
brane composing them firmer. That it is included within that
thin expansion of muscular fibres, called the cremaster. And that
a great number of lymphatics, passing from the testicle to the
receptaculum chyli, are always to be found in it.

An attentive consideration of these circumstances in the struc-
ture of this part will show us, why either obstruction or breach in
the lymphatic vessels, considerable pressure by means of diseased
indurations within the abdomen, or a morbid state of the parts
which should receive the lymph from the vessels of the spermatic
chord, may induce the disease in question; and also, when it is pro-
duced, that its appearance, and nature of the extravasation, must
make the term cellular a very proper one, as expressive of its true
state. k

When the disease is simple, it is perfectly local; that is, it is
confined entirely to the membrane forming the tunica communis;
and does not at all affect, either the dartos, the tunica vaginalis
testis, or any other part.

It is a complaint which does not give a great deal of trouble
unless it arrives to a considerable size; and being by no means so
frequent as either of the other two kinds of hydrocele, it is in gene-
ral but little known or attended to. With some, it passes for a
varix of the spermatic chord; with others, for the descent of a

k "J'ai souvent vu des lumeurs aqueuses, grosses comme des grains de
" rasin, plueees d'espace en espace le long du cordon spermatique, accompa-
" gner une veritable hydrocele placee surle corps du testicle."

Le DitAN.

The first part of this paragraph is a just and true description of the hydro-
cele of the cells of the tunica communis, when not much distended: but if by
"une veritable hydrocele," Mr. Le Dran means that of the tunica vaginalis,
his description of it, as « une tumeur aqueuse, placee surle corps du testi-
cule," is very inexpressive, inadequate, and likely to convey an erroneous
idea.

A TREATISE ON THE HYDROCELE. 33

portion of omentum, which having contracted an adhesion cannot
be returned. Thus its true nature not being in general rightly
understood, and it giving but little trouble or uneasiness while it
is within moderate bounds, and neither hindering any necessary
action or faculty, they who have it are most frequently advised to
be contented with a suspensory bandage, and find very little incon-
venience from it.

Sometimes it arises to so large a size, and gets intosueh a state,
as to become an object of surgery, and to require our very serious
attention.

In general, while it is of moderate size, the state of it is as fol-
lows. The scrotal bag is free from all appearance of disease;
except that, when the skin is not corrugated, it seems rather fuller,
and hangs rather lower on that side than on the other, and if sus-
pended lightly on the palm of the hand, feels heavier: the testicle,
with its epididymis, is to be felt perfectly distinct below this ful-
ness, neither enlarged nor in any manner altered from its natural
state: the spermatic process is considerably larger than it ought to
be, and feels like a varix, or like an omental hernia, according to
the different size of the tumor: it has a pyramidal kind of form,
broader at the bottom than at the top: by gentle and continued
pressure it seems gradually to recede or go up, but drops down
again immediately upon removing the pressure; and that as freely
in a supine as in an erect posture: it is attended with a very small
degree of pain or uneasiness; which uneasiness is not felt in the
scrotum, where the tumefaction is, but in the loins.

If the extravasation be confined to what is called the spermatic
process, the opening in the tendon of the abdominal muscle is
not at all dilated, and the process passing through it may be very
distinctly felt; but if the cellular membrane which invests the
spermatic vessels within the abdomen be affected, the tendinous
aperture is enlarged; and the increased size of the distended mem-
brane passing through it, produces to the touch a sensation not
very unlike that of an omental rupture.

While it is small it is hardly an object of surgery; the pain or
inconvenience which it produces being so little, that few people
would choose to submit to an operation to get rid of it; and it is
very seldom radically curable without one: but when it is large,

vol. n. E

A TREATISE ON THE HYDROCELE.

or affects the membrane within the cavity as well as without, it
becomes an apparent deformity, is very inconvenient both from its
size and weight, and the only method of cure which it admits is
far from being void of hazard; as must appear to every one
who will consider, or who is at all acquainted either with the
nature of lymphatic extravasation or absorption, or with the
frequent consequences of wounds inflicted on parts merely mem-
branous.

CASE VIII.

A man about fifty-five desired me to look at a rupture, under
which he said he had laboured for several years. For the greatest
part of that time he had worn a steel truss, which had given him
little or no uneasiness, but had never kept his rupture up. Dur-
ing all this time he never had any symptoms of obstruction in the
intestinal canal; nor had the tumor ever increased in size, or alter-
ed its appearance, until within the last three or four months, when
he had been persuaded to change his truss for a bandage without
iron, and to make use of an external application, which was said
to be infallible.

What the application was I know not; but its effect was an
excoriation of the groin and parts about: the bandage was made of
■dimity, had a large hard bolster, with three or four buckles, and
was buckled on very tight.

He said, that the pain it had caused had been great; but that
he had cheerfully submitted to it, having been assured that the
medicines, assisted by the pressure, would soon shrink up a
piece of caul which was in the scrotum, and thereby free him
from all possibility of a return of his disease; and that after that
was done, he might leave off all kind of bandage, and do as he
pleased.

He had now made the experiment, till the pain was so great,
and the parts so swelled, that he could endure it no longer. The
scrotum was much inflamed, and swelled; the groin excoriated-
the testicle enlarged, but not hard; the spermatic process quite
up to the belly, full, tight, and so exquisitely painful that he

A TREATISE ON THE HYDROCELE. 35

could not bear the most gentle handling; he had no obstruction
on his going to stool; nor any symptom of the confinement of any
part of the intestinal canal. The principal information which I
could get was from his own account; for he could not bear the
slightest touch. From this it appeared to me, that whatever might
be the true state of the case, it was very clear, that the first thing
to be done was to obtain ease. I therefore put him to bed, bled
him freely, ordered him to have a clyster thrown up immediately,
and to take two spoonfuls of a purging mixture every two or three
hours, until he should have a free discharge per anum; and then
to take a grain of extract, thebaic. I wrapped up the scrotum,
and covered the groin and pubes with a warm soft poultice, and
put on a bag truss.

He passed the day in a very uneasy restless state; and in the
evening, finding his pulse not at all lower, nor his pain less, (his
purging mixture having done its duty,) I took away fourteen
ounces more of blood, and ordered his opiate to be taken again,
and repeated at the distance of every six hours. Forty-eight
hours passed over, during which time he took seven grains of
opium, before he could get sleep or ease; and when he obtained
the former, it did not last more than three or four hours (an effect
I have several times seen, in the exhibition of large and fre-
quently repeated doses of opium, given either to appease pain, or
to quiet a phrenzy).

When he awoke, he was easier, and seemed to be much re-
freshed; his pulse was softer, his perspiration free, and the parts
less inflamed, and less painful; his poultice was renewed after
fomentation; and he was directed to take a draught of the com-
mon emulsion every six hours, with some manna and nitre in it;
by which means he had, in the course of the next day, two plenti-
ful discharges by stool.

By these means, within the space of six or seven days, all his
inflammatory symptoms were removed; and the parts reduced to
nearly the same state in which they were when he put on his
dimity bandage: that is, the testicle was of its natural size, but
the spermatic process large and full, though soft and indolent, and
feeling very like to a small omental rupture.

36 A TREATISE ON THE HYDROCELE

For greater certainty, I kept him in bed a day or two more,
and confined him to tlte same low regimen, with an open body.

The spermatic process continued in the same state. I at-
tempted to reduce the apparent rupture, but without success;
though there was no reason to think that there was the least
stricture made on it by the tendon of the abdominal muscle. I could
indeed make a small part of it recede, but even that did not pass
the opening at all like a piece of omentum; it did not give any of
that sensation to my fingers, nor produce that kind of noise, which
the return of a rupture into the abdomen generally does; and the
moment I removed my fingers, it fell down again, although the
patient was in a supine posture. In short, I made attempts for
reduction so long, and so often, that I was perfectly satisfied that
the prolapsed part was not reducible (at least by me).

It now gave him no pain, nor uneasiness of any kind: but he
had suffered so much from the pressure of his bandage, and was
so satisfied (from the successless attempts which I had made) that
his rupture was not capable of being reduced, that he contented
himself with a common suspensory bag, and found not the least
alteration in it for the space of three years. At the end of this
time he was attacked with a peripneumony, and died.

I obtained leave to examine his body, and found, that what I
had taken for a portion of omentum was a collection of water
in the cells of the tunica communis of the spermatic Vessels, on
the outside of the cavity of the abdomen; that nothing else had
passed through the tendon of the oblique muscle; and that the tes-
ticle and tunica vaginalis were perfectly unaffected.

Notwithstanding the account which this patient had given of
himself, and of his having frequently reduced his rupture, I am sa-
tisfied he never had one; and that his disease had, from the first
been what it at last appeared to be. There was no sign of a her-
nial sac; and though the return of such sac back again into the
belly, after it had been in the groin or scrotum, is a thing much
talked of by late writers, I do not believe that it ever happened.

The steel truss did not press hard enough to produce anv mis-
chief, and was thought not to have kept his rupture up; and the
symptoms, under which I found him labouring, were occasioned
merely by the dimity bandage, substituted in the pl ace f his

A TREATISE ON THE HYDROCELE. 37

truss; which having large hard bolsters, and being buckled on
very tight, pressed violently on the spermatic vessels and loaded
membrane.

CASE IX.

A healthy middle aged man, applied to me one day, while 1
was dressing the hospital, and showed me a considerable swelling
in his scrotum. I examined it, and told him I believed it to con-
sist of water. He replied, he knew it: for that Mr. Baker, then
one of the surgeons of the Westminster infirmary, had a few days
before drawn some from it by puncture with a lancet. Upon hear-
ing this, I examined it again; imagining that I might possibly find
it to be blood (a circumstance which now and then happens, after
tapping a common hydrocele): but still it appeared to me to have
all the marks of a tumor from water, and to be principally in the
spermatic chord. The dartos was indeed a little thickened by the
insinuation of a small quantity of a fluid into some of its cells, but
the testicle was much too plainly distinguishable for the case to
be taken for a hydrocele of the tunica vaginalis; nor was the upper
part of the process in that free state in which it is most frequently
found in that disease. I took him into the hospital, and ordered
him to keep his bed, till I saw him the next day; at which time I
passed a small trocar into the anterior part of the tumor a little
higher than usual. At first a limpid serum flowed freely; but that
soon stopped, and I was necessitated to pass a probe frequently
up the cannula, to get away the remainder; neither could I, either
by that means, or by pressure, reduce the scrotum to a proper size,
or remove the fulness of the process above. I ordered the part to
be fomented night and morning, and the whole scrotum and
groin to be covered with a soft poultice; and that the man should
take a solution of manna and Glauber's salt the next morning.
The applications were continued, and the purge repeated every
second or third day, for a fortnight; at the end of which time, the
swelling was as large as when I first saw it,

During this interval of time, I frequently examined the parts;
and always found the testicle. much more free, and independent,

A TREATISE ON THE HYDROCELE.

than I had ever felt it in a hydrocele of (he tunica vaginalis. It ap-
peared io me, from the kind of fluid which had already been twice
let out, and from the present appearance of the part, that no cure
would be obtained without laving the whole open; but as I was
by no means certain, what was the precise nature of the disease,
or in what state the parts might be found, I informed the man that
it might possibly become necessary to remove that testicle. To
this he consented; and I made an incision, through the skin, from
the groin down as low as the testicle; intending, if I had found the
process diseased, to have castrated.

The incision was followed by a large discharge of water, not
only from the lower part, where there seemed to have been a con-
siderable collection in one cavity, but from the surface of the
whole cellular membrane enclosing the spermatic vessels. Finding
this membrane no other way diseased than by the watery disten-
tion of its cells, I went no farther with my operation, but filled
the incision lightly with soft lint. For three or four days the dis-
charge of serum was large; but, that ceasing, a plentiful suppu-
ration succeeded; which was followed by a perfect subsidence of
the whole tumor; and in due time the wound healed, and the man
obtained a cure.

CASE X.

A gentleman, about thirty-five years of age, came out of the
North, to London, for the assistance of Mr. William Sharpe, in the
case of a large tumor of the scrotum; which, he said, had been
coming five or six years.

The account which he gave of it was, that at first it was small
easily (as he thought) put up, but came down again immediately;'
which he attributed to his not having been accommodated with a
proper bandage; that, at the end of about nine months, or rather
more, he found that he could not reduce it at all, what ver pains
he took, or whatever posture he put himself into; and that from
this time its increase had been daily more apparent. The Z
was singular, and Mr. Sharpe desired me to see it with h

A TREATISE ON THE HYDROCELE. 39

The scrotum was of a most prodigious size; it hung more than
half way down to the patient's knee; it was very ill supported, by
an awkward bag of his own making; and, toward the lower part,
was much ulcerated, by neglected excoriations. Different parts of
the tumor felt very differently; in some places, it was hard; in
some, soft; and, in others, a thin fluid was palpably discoverable.
The spermatic process was large and full, quite up to the groin;
the aperture in the abdominal muscle was considerably dilated by
it; and, when the patient coughed, the whole tumor was mani-
festly distended: his stools were regular, his appetite good, his
urine proper in quality, but very deficient in quantity; his sole
complaints were, a pain in his back, (proceeding, as we supposed,
from the weight of the scrotum,) and a languor and dispiritedness,
which he had not not been accustomed to, and could not account
for.

The feel of some part of the tumor was like that of an intestinal
hernia, in which there is no stricture, and the gut does its office in
scroto; but, other parts of it were so unlike to this, and the upper
part of it toward the groin was so large, and so hard, that we re-
mained in great doubt concerning the true nature of the con-
tents.

When we had sufficiently examined the tumor in an erect pos-
ture, we put the patient into a supine one, which produced a consi-
derable alteration in the appearances; the tumor became mani-
festly less, and softer; and seemed, by retiring, to occasion a large
swelling on that side of the belly, just above the os ilion, tending
backward toward the region of the kidney. Upon continued pres-
sure, the contents of the scrotum seemed to recede still more; and
still as they receded, the swelling on the side of the belly increased.

When we had got up to a certain point, we could get up no
more; but, during our endeavours to return as much as we could,
we clearly discovered that the tumor in the scrotum, and that
within the belly, were produced by the same body; that there was
a palpable and free fluctuation, from the one to the other; and
that the harder parts were mere indurations, and thickenings of
the integuments and common membrane.

The burden was so great, that the patient was desirous of being-
eased, at any rate. We communicated to him our opinions, our

40 A TREATISE ON THE HVDROCELL.

suspicions, fears, and uncertainty; and told him what hazard
might possibly be incurred by acting according to the former, if
we should be mistaken; but, he being determined to endeavour to
obtain relief, at all events, and we being prepared, as well as we
could, for whatever might happen, made a small incision into the
lower and anterior part of the tumid scrotum.

As soon as we had divided the skin, a quantity of clear limpid
water burst forth, of which we caught above a quart; and then the
opening was slopped, by something which thrust itself out, and
looked like a piece of cellular membrane loaded with water. We
cut a part of it off, and gently pushed back the rest with a probe;
while, bv moderate and continued pressure, we drained off eleven
Winchester pints of water.

When we could get no more away, we would have enlarged the
opening; but, our patient found himself so lightened, and so easy,
that he would not permit it.

The scrotum, it is true, was considerably lessened; but in no
proportion to the quantity of water which had been drawn off: the
whole spermatic process, from the testicle quite up to the belly,
was still large and full; and the abdominal opening still dilated by
a large body passing through it; but, as the swelling in the belly
could not now be felt in any posture, and as the scrotum was re-
duced to such a size as to be easily supportable by a bag truss, he
determined to wait the effect of what had already been done. In
little more than a month we saw him again. The tumor in the
side of the. belly was as apparent, the fluctuation as palpable, and
the burden as great, as when we first saw him. His health was
still good in general; but his face appeared to me to be more
pale and wan, and he complained still more of thirst and lan-
guor.

As we were now sure of the nature of the contents, we divided
the whole scrotum from the bottom upward. The lower part was
formed into a cyst, or bag, made by the pressure of the water,
which was discharged upon the first introduction of the knife- but
all the rest of the tumor was formed by the diffusion of serum
through all the structure of the tunica communis, the cells of
which were all much enlarged with it, quite up to the groin- the
testicle being very distinct, and free from disease. The serum

LEAT1SE ON THE HYDROCELE. 41

(i freely from all parts of this membrane by gentle pressure;
and as it seemed to subside considerably thereby, we meddled no
farther, but contented ourselves with filling the incision lightly
will) dry lint, and suspending the scrotum in a bag truss.

During the first two or three days, the discharge of water was
constant and plentiful; and the sore was (as might be expected)
crude and undigested; but without any of that inflammatory hard-
ness and swelling, which wounds made in such parts, in healthy
sanguine people, generally have; on the contrary, the lips were
flaccid, and soft: is is true, he was perfectly free from fever or
pain, and, except the circumstances just mentioned of thirst and
languor, he had no apparent disorder; but they were great and
troublesome. The discharge of water continued large, and his
wound neither digested nor inflamed; nor did it wear any the
least appearance of gangrene or mortification: his languor and
anxiety increased daily; and on the fourteenth day from that of
the operation, he died; the sore still wearing the same face.

Upon opening his body, w*e found all the cellular membrane
which invested the spermatic vessels within the abdomen loaded
with water, and distended in a very irregular manner, from the
origin of the said vessels quite down to the opening of the oblique
muscle. At this place it was contracted into a round, or rather a
flattish body, of less size, but still so large, as to dilate the open-
ing in the tendon considerably. Below this it was again expanded
and distended with water, through all its cells; but the testicle,
and its tunica vaginalis, were in a sound state, and perfectly un-
affected by the disease.

Was it the large discharge of serum, or the free division of
membranous parts which occasioned this gentleman's death? For
my own part, I am inclined to attribute it to the former; for though
an incision, made in parts of such structure, and so diseased, does
sometimes prove fatal, yet the parts themselves in such case gene-
rally show, by a gangrenous or mortified appearance, what share
such operation has in the patient's destruction.

In this case, there was indeed no digestion, nor any of thaf in-
flammation, which always precedes suppuration; nor. on the other

vol. 11. r

{> a TREATISK ON THE HYDROCELE.

hand, was there any appearance like gangrene or sphacelus;
his manner of dying was very much like that of those who are
stroyed by large haemorrhages.

SECT. VI

THE ENCYSTED HYDROCELE OF THE TUNICA COMMUNIS

This species of hydrocele has its seat in the same part as the
preceding; viz. the tunica communis, or cellular membrane, which,
invests the spermatic vessels; with this difference, that, in the
former, the water is diffused in general through all the cells of
the membrane; whereas in this, it is contained in one cavity only.
If any of the three kinds of hydrocele deserves the name of en-
cysted, it is this. The water which constitutes it being all con-
tained in a bag, formed in the same manner as all the coats of all
encysted tumors are; viz. by mere pressure, and condensation of
the common membrane.

It is a complaint by no means infrequent, especially in children.
It was very well known to many of the ancients, and has been
very accurately described by some of them;' but later writers have

' By Albucasis, by Celsus, Paulus JEgineta, and others. The last has par-
Ocularly distinguished this kind of hydrocele from that of the tunica vaginalis,
by a very just description of both: «' Si humor in membrana supernata coierit,
"tumor altem.s testicuh imaginem cxhibet. Quibus in Epythroide tunica

humor comprehends est tumor rotundus paululum, et ovi modo longius-
"pt!L'' St ^ inCOns P ectumno ™*> «tqui undiquaquesit im-

The former of these descriptions, our countryman TW„ r u

probably copied, when he says, , ,t is -wedJTSj^ i ^ k

"and appeareth like a third testicle." d '" a membrane '

Heister speaks of this species of hydrocele as very rare « i
authority of others to prove its existence, and seems inson,' Y ^^
found it with a collection of fluid in a congenial hernial sac mtaSUre t0 COn '

Page 842, he says, « Quandoque tamen etiatn, ut nonnulli autor*. f
"mpentonxi processu, supra testiculum, liquor prater nit., referunt '

intmram colligitur ;

A TREATISE ON THE HYDROCELE. 43

often mistaken it for, and represented it as, a species of wind-
rupture, or pneumatocele; a disease existing in their imaginations
only. It most frequently possesses the middle part of the process,
between the testicle and groin, and is generally of an oblong figure;
whence it has by some people been compared to an egg, by others
to a fish's bladder. Whether it be large or small, it is generally
pretty tense, and consequently the fluctuation of the water within
it not always immediately or easily perceptible; for which reason
it has been supposed to contain air only. It gives no pain, nor
(unless it be very large indeed) does it hinder any necessary
action. It is perfectly circumscribed; and has no communica-
tion, either with the cavity of the belly above, or that of the
vaginal coat of the testicle below it. The testis and its epididy-
mis, are perfectly and distinctly to be felt below the tumor, and
are absolutely independent of it. The upper part of the spermatic
process in the groin is most frequently very distinguishable. The
swelling does not retain the impression of the fingers; and when
lightly struck upon, sounds as if it contained wind only. It
undergoes no alteration from change of the patient's posture; nor
is affected by his coughing, sneezing, &c; and has no effect on the
discharge per anum.

These marks (while the disease is simple and uncombined with
any other) are sufficient to distinguish it by, from all others
which may affect the same part: but it sometimes happens, that
the present, complaint is found connected either with a true hernia,
or with a hydrocele of the tunica vaginalis; by which the case is
rendered complex, and less easy to be understood.

"imo etiam in productione peritonaei, ab intestinorum hernia orta, copiosum
"liquorem in cadavere, sectione aliquando deprehendi." And in a note on
this passage he adds, " Wiedemannus, nee non Boerhavius, itemque Garen-
"geotuset Dranius memorant istiusmodi hydroceles casus quandoque ob-
" servari ; ubi digito contingi testiculus queat ; atque tunc supra testiculum in
** peritonaei processu tumorem et humorem consistere. In enterocele autem
" contrarium quandoque usu venire, propterea quod intestina interduni, ut
"supra monui, usque in tunicam vaginalem, per septum illud naturale, quod
" testiculum a parte superior! processus peritonaei distinguit penetraverunt."
" Sed rari admodum sint necesse est, ad quos modo laudati autores pro-
"vocant casus. Ego sane quanquam plurimos homines enterocele, non
'« minus quam hydrocele laborantes sanaverim, nunquam tamen adhuc ita
" rem inveni," &c

44 A TREATISE ON THE HYDROCELE.

In this, as in every other case where, from a complication of
symptoms and appearances, a combination of diseases may be
suspected, there is but one method of investigating the truth;
which is, to consider carefully what disorders the part aggrieved
is naturally liable to; what the distinct symptoms and appearances
of each of those are; and what arc (he effects of the present com-
plaint. The two diseases with which this kind of hydrocele is
most, likely to he combined, are, as I said before, an hydrocele of
the tunica vaginalis testis, and a true hernia; the parts within the
groin, the spermatic process, and the scrotum, being the seat of
all three.

One mark, or characteristic of an hydrocele of the tunica va-
ginalis testis is, that it possesses and distends the inferior part of
the scrotum; and that the testicle being nearly (though not abso-
lutely) surrounded by the water, it very seldom happens that the
former can be clearly and plainly distinguished by the fingers of
an examiner; whereas, in the encysted collection, in the mem-
branes of the chord, the tumor is always above the testicle, which
is obvious and plain to be felt below it.

Another circumstance worth attending to is, that although the
fluid in a hydrocele of the vaginal coat does so nearly surround
the testis as to render it often not very easy to be distinguished,
yet the different parts of the tumor have always a very different
feel: for instance, in all those points where the vaginal tunic is
loose, and unconnected with the tunica albuginea, the tumor is
soft and compressible, and gives a clear idea of the contained
fluid; but when these two coats arc continuous, or make one and
the same membrane, and haveoo cavity between them, (which is
the case on the middle and posterior part,) there will 'always be
found a hardness and firmness, very unlike to what is to be found
in all those places, where the distance"* between the two tunics
leaves room for the collection of a fluid: now, the hydrocele of the
chord being formed in the mere cellular membrane of it, is the

■

- "Tunica Erytbroides natar* nervosa, in gibba quidem et anteriore e tes
" t.culo hbera est, in concava et posteriori ipsi adberescit ex n
" gmem trahens." ^"ciesc.t ex pen.onso on-

A TREATISE ON THE HYDROCELE. 45

same to the touch in all the parts of the tumor, and feels like a
distended bladder through every point of it.

The free slate of the upper part of the spermatic process, while
the tumor is forming below; the gradual accumulation of the fluid,
and consequently the gradual growth of the swelling; the indolent
and unaltering state of it; its being incapable of reduction, or re-
turn into the belly from the first; its being always unaffected by
the patient's coughing or sneezing; and the uninterrupted freedom
of the faecal discharge per anum, will always distinguish it from
an intestinal hernia: and he who mistakes it for 'an omental one,
must be very ignorant, or very heedless.

Now, although there may not always be such external marks
as may, to the eye, explain the combination of these diseases with
each other; yet the particular seat and symptom of each being
known, and the sensations which they produce to the fingers of
an intelligent examiner being well understood, when such mixed
characteristics are found in the same subject, we may reasonably
conclude the case to be complex, and act accordingly.

I have indeed seen an encysted hydrocele, situated so high to-
ward the groin, as to render the perception of the spermatic ves-
sels very obscure, or even impracticable; but then, the state and
appearance of the testicle, and the absence of every symptom pro-
ceeding from confinement of the intestinal canal, were sufficient
marks of the true nature of the complaint.

Infants are much more subject to this disease than adults;
though it often affects the latter.

In young children, it frequently dissipates in a short time, es-
pecially if assisted by warm fomentation and an open belly.

If it does not disperse, that is, if it be not absorbed, the point
of a lancet will give discharge to the water; and, in young chil-
dren, will most frequently produce a cure: but in adults, the cyst
formed by the pressure of the fluid does sometimes become so
thick, as to require division through its whole length; which oper-
ation may in general be performed with great ease and perfect
safety. I say in general, because it is most frequently so; though I
have seen even this, slight as it may seem, prove troublesome,
hazardous, and fatal. Of such consequence are wounds in mem-
branous parts in some particular habits.

46 A TftfcATISE ON THE HYDROCELE

CASE XI.

A lad about sixteen years old was taken into St. Bartholo-
mew's hospital, with a complaint which he had been told was a
rupture.

The tumor was large, of an oblong figure, began just below
the exit of the spermatic vessels from the belly, and extended to
the bottom of the scrotum; but in the middle of it was a depres-
sion, or stricture, which seemed to divide it nearly into two equal
parts. The upper part was so high, that I could not feel the sper-
matic process at all Satisfactorily; and although there was palpa-
bly a tluid in the whole of the swelling, yet the upper and lower
parts of it did not seem to communicate with each other; at least
the fluctuation through them was not discernible. As he had never
had any symptom of a true hernia, and as the account he gave of
the gradual formation of the tumor joined to the fluctuation, &c.
convinced me that it was principally if not totally water, I pierced
the lower part carefully, and drew off nearly half a pint of yel-
lowish serum; by which means the scrotum became immediately
empty and rugous, and the testicle clearly distinguishable; but the
upper part of the swelling remained as large and as tense as be-
fore, nor could I by any means obtain a drop of fluid more from
below.

The next day I ordered him a brisk purge, which operated
well; and two or three days after, being satisfied that the intesti-
nal canal could have no share in the complaint, I thrust a lancet
into the anterior part of the upper tumor; by which means a quan-
tity of limpid serum was discharged; and the whole swelling im-
mediately disappeared, leaving the spermatic vessels free, and
easily distinguishable.

In a few days he left the hospital; and at the end of a year, or
a little more, he came to me again, with the lower part of the
scrotum full, but without any appearance of the tumor above. In
short, his former state consisted of a complication of the encysted
hydrocele of the spermatic chord with that of the tunica vaginalis

A TREATISE ON THE HYDROCELE. 41

a:,->tis: the former was cured by the first puncture, the latter was
now as full as ever. ,

Considering the lad's age and temperament, I advised him to
submit to the operation for the radical cure by incision; which
operation was performed, and he got well in about seven weeks,
hoi has had any return of cither complaint since.

CASE XII.

A man about thirty-five, who had for some years been troubled
with a hydrocele of the tunica vaginalis, which had often been
emptied by puncture, came to me for advice.

The swelling in the scrotum, he said, was now about one-third
of the size it used to be of, when he had been accustomed to have
it tapped; it was not tense, was of an irregular figure, and plainly
contained a fluid. But it was not on account of this tumor that
he applied to me.

Within two months past he had discovered another small
swelling, higher up towards his groin, perfectly distinct from the
lower one: it was about the size of the largest French walnut, of
an oblong figure; absolutely indolent, very tense, and left the sper-
matic process, at its exit from the abdomen, perfectly free.

From the appearance which these tumors made, and from the
patient's account, I made no doubt of the nature of the case;W.
that the upper one was made by a collection of water, in a cyst,
formed in the cellular membrane which makes the tunica com-
munis of the spermatic vessels; and that the lower one was a true
hydrocele of the tunica vaginalis testis.

Upon this presumption, I pierced the upper one with a lancet;
and let out a small wine-glass full of clear limpid serum. The
tumor immediately subsided, and left the whole spermatic process
free; but the lower swelling was not at all affected by what had
been done above. The puncture was well in a day or two; and the
hydrocele of the vaginal coat not being full enough to be at all
troublesome, he would not permit me to meddle with that. At
the end of about nine months he sent for me; his hydrocele was
full and large, but he had not the smallest appearance of the*

48 A TREATISE ON THE 1IVDKOCELE.

tumor iii the process. The water was let out by puncture, as
usual; as it has been several times since; but he has never suffered
any return of the collection in the process.

CASE XIII.

A lad about fourteen years old was brought into St. Bartholo-
mew's hospital for a rupture; which a surgeon (who had seen
him at home) had told his friends was not in a situation to admit
delay: and it being my week for accidents, I was sent for imme-
diately. I found a large tumor, full and tight, possessing the whole
spermatic process and scrotum, from the groin quite down to the
testicle; which was independent of it, and perfectly distinguish-
able. As he lay on his back, it was perfectly indolent; but in an
erect posture, or in the action of stooping, he complained of pain:
it was not tender to the touch, unless pressed hard; and it was
nearly of equal size from the top to the bottom: it bore so hard
against the opening in the abdominal muscle, that I could, by no
means, feel the spermatic process: he said, that it had appeared
within a week, and that he had had no stool for five days past.

Some of these were circumstances of importance, and might be
occasioned by a stricture on the intestinal canal: but on the other
hand, his pulse was soft, calm, and quiet, and his skin cool: he
had neither tight belly, nausea, hiccough, nor vomiting; nor any
other symptom (general or particular) deducible from such cause.

From the mere appearance and feel of the tumor, I should have
supposed it to have been caused by water; but the difficulty of dis-
tinguishing the spermatic process above, the freedom of the testi-
cle below, and the want of stools, made me hesitate.

But though I was in some doubt concerning the precise nature
of the case, yet I was very clear there was no immediate necessity
for an operation. Therefore, having found that I could not return
any part of the contents of the tumor into the belly, I took away
sixteen ounces of blood from his arm, ordered a clyster to be thrown
up immediately, and two spoonfuls of a purging mixture to be
taken every two hours, until a plentiful discharge per anuin should
be procured.

A TREATISE ON THE HYDROCELE'. 49

He took Ins mixture only twice, and had six large stools that
afternoon; and when I saw him the next morning, he was perfectly
well injiealth, but the tumor exactly the same. I examined it
again and again, and was still more positive that it contained a
fluid; but whether that fluid was in the tunica communis, or in a
hernial sac, I could by no means be clear. However, as there
was no possible method of getting rid of it but by an opening, I
determined to make one, with such caution as to be prepared for
whatever might happen.

I made a small incision into the anterior and lower part: when
I had divided the skin and cellular membrane, I found a firm hard
membrane, which I took for the sac of an hernia: this I divided
with the same caution, and gave discharge to a considerable quan-
tity of serum; upon which the whole swelling immediately sub-
sided, the spermatic process appeared in a natural state, and the
opening in the tendon undilated.

The incision was dressed superficially, and healed in a few
days.

Within less than half a year he came to me again, with the
swelling as large, and under the same apparent circumstances, as
before. His habit was so good, and I so well remembered the
toughness of the cyst, at the first operation, that I made no scruple
of advising him to have it laid open through its whole length. To
this he submitted, and obtained a perfect cure.

CASE XIV.

A man, about forty, servant to one of the governors of St. Bar-
tholomew's hospital, came thither for advice concerning a rupture;
which, he said, the surgeons in the country had oficn endeavoured
to put up, but had never succeeded.

The groin and all the upper part of the scrotum were large and full;
but the testicle below very fair, and distinct from the tumor. The
account which he gave was, that he first perceived the beginning
of the swelling, in the evening of a day in which he had ridden a
very hard fox chase, and had been a good deal hurt by a fall over
his horse's head. That at first it was small; and that it had

T[OL. II. G

uO v IKEAT1SE ON THE HYDROCELE.

gradually increased ever since. That it had never been up since
it first appeared. That he constantly felt a dull kind of uneasi-
ness in it; and that it was very troublesome to him when on horse-
back, which he was frequently obliged to be, as his business was
that of an huntsman. I examined the case carefully, and was
satisfied that it was water, and not in the vagina! coat of the tes-
ticle. He had for some time worn a truss, which had rendered
the part uneasy; had lived freely with regard to liquor; had a yel-
lowness in his countenance, which had an unhealthy appearance:
his legs were rather too full; and he had, for a little while past,
been under the direction of a physician in the country.

I did not like his appearance, considering him as the subject of
an operation, and therefore advised him to return into the country,
and continue to follow his doctor's direction.

At the distance of three or four months, he came to the hospital
again. He had now the appearance of very good health. His
countenance was fresh; his appetite keen; his urine in proper
quantity; and his legs fine. His tumor was larger; and he said
it was become so troublesome, that if something was not done for
it, he must quit his service, and go to the parish.

I could have wished, that his former state had been different;
but having apprized him, how much that added to the hazard of
any attempt toward curing him, I made an incision the whole
length of the tnmor, and gave discharge to a considerable quantity
of clear water.

The cyst was firm and thick, and formed in the common tela
cellulosa of the chord.

For three days the wound discharged a large quantity of serum,
but it neither became tumid, nor inflamed; his pulse became hard
and frequent; he was thirsty and restless, and had a languor in
his countenance, which I did not like. On the fourth day the
discharge of water ceased, but the incision stiU remained cold lax.
and flabby; and was so far from showing any tendency to sup-
purate, that, on the contrary, the edges began to be livid.

Bark, and cordial medicines, were prescribed by the ph\ r sician
and fomentation, poultice, and animated digestive dressings were
applied; but to no purpose. On the sixth day he complained of
a burning heat in his back and kidneys, while his extremities were

A TREATISE ON THE HYDROCELE. 51

cold and damp; on the seventh he became delirious, and thai
evening died.

All the cellular membrane in the pelvis, and about the loins
and kidneys, was excessively distended with air, and in several
places discoloured; and in the cavity of the abdomen was a large
quantity of bloody water.

SECT. VII.

HYDROCELE OP THE TUNICA VAGINALIS TESTIS.

The third species of this disease is that which is confined to
the vaginal coat or bag, which loosely envelopes the testicle. In
the short anatomical account already given of the production,
structure, and situation of this tunic, it has been observed, that, in
a natural healthy state, its cavity, always contains a small quantity
of a fine fluid, exhaled from capillary arteries, and constantly ab-
sorbed by vessels appointed for that purpose.

This fluid, in the natural small quantity, serves to keep the
tunica albuginea moist, and to prevent a cohesion between it and
the vaginalis; a consequence, which almost necessarily follows
any such diseased state of these parts, as prevents the due secre-
tion of it. On the contrary, if the quantity deposited be too large,
or if the regular absorption of it be by any means prevented, it
will be gradually accumulated, and, by distending the containing
bag, will form the disease in question.

The two preceding species of hydrocele have their seat in the
tunica communis of the spermatic vessels; that is, in the cellular
membrane which invests them; one by a general diffusion of
lymph through all its cells; the other by a collection of it, in one
particular cyst or bag: that which makes our present subject has
no concern or connexion with that membrane at all, but is abso-
lutely confined to the tunica vaginalis testis."

■ Fallopius, although he was unacquainted with the real and true origin
and nature of this disease, and supposed its manner of production to be very

52 A TREATISE ON THE HYDROCELE.

It is a disease from which no time of life is exempt; not only
adults are subject to it, hut young children are frequently afflicted
with it; and infants sometimes born with it. What is the'imme-
diateiy producing cause, I will not take upon me to affirm. Ruysch
is of opinion, that it proceeds from a varicose state of the sperma-
tic vessels. What real foundation there may be for such conjec-
ture, I cannot say; certain it is, that the spermatic vessels are
very frequently found varicose, in persons afflicted with this kind
of hydrocele; but whether such state of these parts ought to he re-
garded as a cause, or as an effect of the disease, is a matter worth
inquiring into.

In Morgagni arc some observations on the state of the parts
concerned, particularly the inside of ihe tunica vaginalis, and out-
side of the albuginea; which, if repeated and confirmed, may pos-
sibly lead us on to furdier information.

In the mean time, from all the circumstances attending the
complaint, it is pretty clear, thai whatever tends to increase the
secretion of the fluid into the saccuius, beyond the due and neces-
sary quantity, or to prevent its being taken up, and carried off, by
the proper absorbent vessels, must contribute to its production;
which is so slow and gradual, and at the same time so void of
pain, that the patient seldom attends to it, until it has arrived to
some size. Not but that it sometimes is produced very -suddenly,
and in a very short space of time attains considerable magnitude.

The size and figure of the tumor are various in different peo-
ple, and under different circumstances. In general, at its first be-
ginning, it is rather round; but as it increases, it frequently as-
sumes a pyriform kind of figure, with its larger extremity dovvn-

unlike what it really is, lias yet given a very just account of the appearance,
both of this and of the former : " Alia vero est hernia aquosa, in qua aqua dis-
"tillat per vasa et venas, occulto modo, ac sensim ad scrotum. Hsec aulem
"est duplex ; alia in qua continetur aqua in membrana adnata, el in proprio
"folliculo; alia in qua contiuetsr in inguinale tunica qnuc testem vestit. Cog 1 -
"noscitur aquam esse in tunica adnata quia separatur testis a parte aquosa
"manibus; praeterea, ista hernia habebit propriam circumscriptionem, ali-
"quando rotundam, aliquando ovalem. Si autem fit in vaginali, non possumus
"arnplius arripere ct distinguere testem ab hernia ; quoniam in eodem loco et
" aqua, et testis sunt constituti."

Gati. Faliqpivs

A TREATISE ON THE HYDROCELE. 53

ward: sometimes it is hard, and almost incompressible; so much
so, that, in some few instances, it has been mistaken for an in-
duration of the testicle: at other times it is so soft and lax, that
both the testicle and the fluid surrounding it are easily discover-
able. It is perfectly indolent in itself; though its weight does
sometimes produce some small degree of uneasiness in the back.
The great characteristic (as it is called) of this disease, and on
which almost all writers have agreed to lay the greatest stress,
and to rest their proof of the nature of the disorder, I mean the
transparency of the tumor, is the most fallible and uncertain sign
belonging to it: it is a circumstance which does not depend upon
the quantity, colour, or consistence of the fluid constituting the
disease, so much as on the uncertain thickness or thinness of the
containing bag, and of the common membranes of the scrotum.

If they are thin, the fluid limpid, and the accumulation made
so quick as not to give the tunica vaginalis time to thicken much,
the rays of light may sometimes be seen to pass through the tu-
mor: but this is accidental, and by no means to be depended upon.
Whoever would be acquainted with this disorder, must learn to
distinguish it by other, and those more certain marks; or he will
be apt to fall into very disgraceful, as well as pernicious blunders.
The colour of the fluid is very different and uncertain; sometimes
it is of a pale yellow, or straw colour; sometimes it is inclined to
a greenish cast; sometimes it is dark, turbid, and bloody; and
sometimes it is perfectly thin and limpid.

In the beginning of the disease, if the water be accumulated
slowly, and the tunica vaginalis thin and lax, the testicle may
easily be perceived; but if the said tunic be firm, or the water ac-
cumulated in any considerable quantity, the testis cannot be felt
at all; and other symptoms, or marks, must be attended to. In
most cases, the spermatic vessels may be distinctly felt at their
exit from the abdominal muscle, or in the groin; which will al-
ways distinguish this complaint from an intestinal hernia, the dis-
ease which it is most likely to be confounded with. It does in-
deed now and then happen, that the vaginal coat is distended so
high, and is so full, that it is extremely difficult, nay, almost im-
possible, to feel the spermatic process; and it also sometimes hap-
pens, that the same kind of obscurity is occasioned by the addi-

54 A TREATISE ON THE HFDROCELL.

lion of an encysted collection of water in the membrane of the
chord; or by the case being combined with a true enterocele.
These circumstances are not very frequent, but yet do occur often
enough to render it well worth while to mention them; and to
signify that, when tlicy ore met with, recourse must be had to
other marks.

The general notion formed of this disease is, that it consists of
a bag, filled with a fluid, in the middle of which the testicle hangs
suspended, and by which it is completely surrounded.

This idea is not oidy erroneous, and contrary to fact, but may-
be productive of very mischievous consequences in practice. For
from such conception (or rather misconception) of the state and
disposition of the parts, it may be inferred, thai all points of the
tumor are equally fit for such operation as may become necessary
for the discharge of the fluid; which is so far from being the case,
that, in some parts of it, such operation is perfectly safe, easy,
and harmless; in others, it is hazardous, painful, and may be pro-
ductive of the most dreadful consequences. Whoever will take
the pains to examine the structure and disposition of the two coats
of the testicle, the albuginea and vaginalis, will find, that in one
part they are so inseparably united, (being indeed one and the
same membrane.) that is impossible for any thing to insinuate it-
self between them: while in every other part they are so abso-
lutely unconnected, that from the great dilatability of the latter, a
large quantity of fluid may be accumulated.

In a hydrocele which is tolerably full, the place of this union is
the posterior and superior, or rather the posterior and middle part
of the tumor. A puncture or incision made here will do no ser-

° " Humor magna ex parte, in tunic* Erythroide appellata, tcsticultim am-
" blertte, in partem anterhrem colligitur; qua potissimum membrane, ilia a testi-
" culo separator."

Paulls JEgijjeta.

Mr. Le Dran, whose character in practical surgery stands deservedly high,
seems to be less clear in his idea, and less perspicuous in his account of this
disease, than of most others: his account is, " Unc vessie auqeuse placee sur
" l'un de testicules, auquel elle est adherente ; et comme elle devient quel-
" quefois tres grosse, elle remplit presque tout le scrotum." . This does not
at least to me) convey an idea that the seat of this disease is within t''
Vaginalis testis,

A TREATISE ON THE HYDROCELE. 55

vice, as it cannot reach the water, and therefore cannot answer
the intention for which it ought to be made; hut it will injure the
testicle, or its epididymis, and thereby do great mischief; whereas
an opening made in every oilier part, will not only give discharge
to the water, hut can do no harm, and is free from all kind of
danger.

This natural connexion between the two tunics, at the upper
and hinder part, is the reason why, in a simple hydrocele, that
part of the tumor feels so very unlike to every other. In that, the
tunica albuginea, and vaginalis, being immediately continuous, no
water can get between them; and therefore, the fingers of an in-
telligent examiner must immediately discover the firmness and
hardness arising from the union of these parts: in all others, the
two membranes being unconnected, and affording a void space for
the collection of water, the fluctuation of it will always be distin-
guishable.

This is a circumstance which must for ever discriminate the
simple hydrocele of the tunica vaginalis, from the anasarcous
swelling of the scrotum; from the encysted hydrocele of the chord;
and from the intestinal hernia. The first is every way equal,
tumid, and soft; and every where ecjually receives and retains the
impression of the fingers: the second, though circumscribed, not
very compressible, and affording the sensation of fluctuation, yet
does not pit, and is alike to the touch in all parts of it: and, in
the third, if the testicle be distinguishable at all, it is found at the
inferior part of the whole tumor.

An indurated or scirrhous testicle lias indeed, very frequently^
a quantity of fluid lodged in its vaginal coat; which is a circum-
stance not to be wondered at; the diseased state of the gland being
sufficient to account for the non-execution of the absorbent faculty,
and, consequently, for the collection of the water. But although
part of this mixed tumor is undoubtedly owing to a fluid, and such
fluid as is lodged within the vaginal coat, yet it is a very different
disease from the true simple hydrocele, and ought not to be con-
founded with it; one of these marks of the latter being the natural,
soft, healthy state of the testicle: and the characteristic of the
former being its diseased and indurated enlargement.:'

f When T say natural, soft ( and healihy state of the testicle, I do not mean,

56 A TREATISE ON THE HYDROCELE.

This is a point of more consequence than it may, perhaps, upon
a cursory view, seem to be. It not only regards the definitions,
but the treatment of the diseases: and, being rightly understood,
and attended to, or not, may be productive of much good or ill.

We are, by most of the writers on this subject, advised in ope-
rating for the radical cure of an hydrocele, to regard carefully the
state and condition of the testicle; and, if we find it enlarged, har-
dened, putrid, fungous, or any other way really diseased, to remove
it immediately: which advice, within proper limitations, is cer-
tainly good. A testicle, in almost any of the just mentioned cir-
cumstances, ought undoubtedly to be removed: but these cautions
have nothing to do with the true, simple hydrocele; and can relate
only to the diseased, the scirrhous, or the cancerous testicle. When
these disorders are the subject of consideration, then such hints and
cautions make a very necessary part of it; but they can have no
concern with the present/'

that the testicle, in a true, simple hydrocele, is never altered from its natural
state, when unaffected by any disease : I know the contrary ; 1 know that the
testicle, in a hydrocele, is very frequently enlarged in size, and relaxed in
structure, as well as that its spermatic vessels are often varicose; I use the
words in opposition to the diseased indurated slate of the scirrhous testis.

•i " Xamque ubi forte vel putredo, vel scirrhus, vel alia qua:dam corruptio
" vehemens lesticuhim invasdt, sakitarius exscindere."

Heisteh.

This is also the doctrine of most of the writers (a large number in sugery)
who have copied each other, both in their ideas of diseases, and in their pro-
posed method of tueating them.

Not writing from practice, or from what they have seen, they have related
circumstances, under the article of the simple hydrocele, which never occur
and have directed a method of conduct, which, if followed, must mislead the
surgeon, and subject the patient to pain, fatigue, and even loss of parts, with-
out any the least necessity. Under the head of radical cure of the simple
hydrocele by incision, Heister has mentioned several circumstances as neces-
sary to be attended to for the regulation of the operator's conduct, which
circumstances do not occur in that disease : " Deligari autem vasa sperma-
" tica filo, rescindique testiculus omnino debet sicuti in cap. de sarcocele do-
" cuimus, quoties vasa seminalia, non insigniter tantum induruerunt, sed mag-
" nis quoque cruciatibus hominem segrum affliguent. Despiciendum
quoque porro est num testiculus tumefactus forte materiam aliquam
" fluidam, sicut quandoque contingit, intus contineat. Si quid enim fluidi
" intus hxrere tactu percipimus, aut lympham, aut pus inibi consistere rec-
"tissime colligimus. Interim neque tunc rescindei-e conUnuo (ut nonnullent,") '
" sed incidere potius, atque expurgare testiculum istum conveniet, 8cc. Sed

A TREATISE ON THE HYDROCELE. 57

The truth is, that the majority bolh of the ancient writers and
practitioners, misled by the sound of the term hydrocele, have
mistaken a mere accidental effect for a cause; and'have supposed
that the fluid contained in the tunica vaginalis testis may not only
constitute a disease by the mere distention of it; but may be pro-
ductive of other diseases of the testicle itself. They have fancied
the water to have in itself a noxious quality, or disposition; and
that the testicle, by merely swimming in it, might become dis-
eased, and unfit for use; whereas in cases wherein a disordered
state of the testis accompanies a collection of water in its vaginal
coat, the truth is just the reverse of this supposition: the testis is
first diseased, and the faculty of equal, regular absorption thereby
interrupted; by which means a quantity of fluid is accumulated*,
and that mixed appearance produced, which is not improperly
called hydro- sarcoccle. But in this case, the extravasation of wa-
ter is really the consequence of the morbid state of the gland; and
(being still mere simple lymph) neither is, nor can be the cause
of it.

They who choose it may call this a species of hydrocele; and
the literal sense of the word will certainly vindicate them; but
they will by that means run the risk of confounding together two
things extremely unlike to each other, and which require very
different treatment: I mean the true simple hydrocele, in which

" si forte simul nimis jam tunc induratus, vei corruptus idem inveniatur, pre-
"dicta ratione, ligmdus et resecandus, ne in carcinoma forte abeat."

That such state of the spermatic vessels and testicle does occur is beyond
all doubt; but not in the simple hydrocele; not in die hydrocele that any ra-
tional practitioner can possibly deem fit for the attempt for the radical cure
by incision. Neither is it possible for a man, who understands the disease at
all, not to be acquainted with these circumstances before he attempts such
operation ; and if he is previously acquainted with them, he must be a very-
extraordinary man indeed to set about relieving them in such a manner. If
the state of the testicle and its vessels be such as to require castration, (a
thing always capable of being known before hand,) let that operation at once
be performed, in a proper and expeditious manner, and not by piece-meal, as
it is here described. If castration be not requisite, neither can any other
part of the operation (with regard to the testicle) be so ; for, notwithstanding
these descriptions of incisions into, and expurgations of, diseased testicles
may make a figure in books, they are very unfit to be introduced into prac-
tice. They never can do good: they roust do unwarrantable, and generally
irremediable, mischief

VOL. II. II

DO A TREATISE ON THE HYDROCELE.

the testicle is soft and sound, (only perhaps a little more lax, and
larger than ordinary,) and the hydro-sarcocele, in which the tes-
tis is not only enlarged, but hardened, and not in a sound or
healthy state: the former of these will permit such treatment with
perfect safely; but in the other, may bring the patient into a state
both of pain and hazard/

It may indeed, and does sometimes, become necessary to let
out the water from the vaginal coat of a testicle, in some degree
diseased: but this should always be done with caution, and under
a guarded prognostic; lest the patient be not only disappointed, by
not having that permanent relief, which for want of better inform-
ation he may be induced to expect; but be also (possibly) sub-
jected to oilier unexpected inconveniences from the attempt.

Upon the whole, as just definitions, and accurate distinctions of
diseases from each other, are absolutely necessary towards under-
standing them rightly, it seems to me much more proper to con-
fine the term- hydrocele to the mere simple accumulation of a fluid
within the coats of the sound testicle, and to refer all those which
either are combined with, or proceed from, diseases of that gland,
to another class.

When the disease is a perfect, true, simple hydrocele, the tes-
ticle, though frequently somewhat enlarged, and perhaps loosened
in its vascular texture, is nevertheless (as I have already observed)
sound, healthy, and capable of executing its proper office: neither
is the spermatic chord any way altered from a natural state, ex-
cept that its vessels are generally somewhat dilated; neither of
which circumstances are objections either to the palliative or ra-
dical cure of the disease. But in those disorders, which in some
degree resemble this, the case is different; either the testicle, or
spermatic chord, or both, bearing evident marks of a diseased
state. In the true, simple hydrocele, the water is accumulated

1 Some instances of this are related in this tract. Hildamis has given a
particular account of a mistake of this kind: " Inciso scroto plurimum affluxit
" aqua, hinc primo subsedit scrotum; post paucos tamen dies secutus est
" dolor, vehemens inflammatio et cancrosum ulcus, maximeque malignum;
" quod adeo impetuose adjacentes partes occupavit, uliupsius malignitas nu!-
" lo modo arceri possit ; sed intra paucos dies maximo cum cructatu e vita
" decessit,"

A TREATISE ON THE HYDROCELE. 59

merely from the non-execution of the office of the absorbent ves-
sels; which (whatever ultimate cause it may have) leaves no ap-
pearance of real disease on the parts: in all the other collections
of fluid in this part, there are such appearances and marks of dis-
temper, as may clearly convince us, that the extravasation is only
a consequence of such state.

The two principal complaints, liable to be mistaken for an hy-
drocele, are, that kind of scirrhous testicle in which an extravasa-
tion of fluid is made in the tunica vaginalis; and Hie venereal in-
duration of the testicle, attended with the same circumstance.
One of these is always a disease of the general habit; the other
too often so.

One requires, and generally submits to, a proper course of spe-
cific remedies; for the other (notwithstanding all that has been
said on the subject) we as yet know of none; and therefore it is
seldom cured but by total removal. In neither of these, can the
mere discharge of the fluid contribute any thing material toward
a cure; and in both of them, such attempt, injudiciously made,
has often proved both painful and hazardous.

In the true venereal sarcocele, or indurated testis, the disease
ought always to be eradicated from the habit before any attempt
be made locally: the mere discharge of the water can never
remove the obstruction in the gland; but when such obstruction
has been by proper remedies removed, it is no uncommon thing to
have the extravasated fluid again absorbed; or if it be not, and any
operation becomes necessary, a soft, easy, healthy state of the testi-
cle is certainly preferable to an indurated diseased one.

These two cases, or, to speak more properly, these two states
of the testicle, although they agree in this one circumstance of
not being essentially relieved by the mere evacuation of the water,
do yet differ so widely in almost every other, that it behoves prac-
titioners to be very careful in distinguishing between them. That
method of treating the venereal induration, which is most fre-
quently successful, will prove highly prejudicial in the scirrhous
hardness. By mercury, in judicious hands, the pocky patient's
disease may be removed, and his health restored: but I have hardly
r ever seen a scirrhus or cancer that was not exasperated, and made
worse by it. Or, if that does not happen, yet, a mercurial course, in

60 A TREATISE ON THE HYDROCELE.

such case, will always occasion a loss of time, which is not always
retrievable. In short, he who treats a scirrhous testicle as be
ought to do a venereal one, will not cure the disease, but waste
his patient's time, and hurt his general health: and he who treats
a venereal one as he most frequently ought to do a scirrhus, will,
without any necessity, submit his patient to a painful operation,
and thereby deprive him of a part very essential to him as a man.

CASE XV.

A gentleman, about thirty years old, showed me liis testicle,
which was both enlarged and hardened, and had very palpably a
quantity of fluid in the vaginal coat. He had been told, that it
was a water rupture, and that it might be immediately cured by
meansof a small incision.

The whole testicle and epididymis were" (as I have already
said) large and hard; and so were the vas deferens, and part of the
spermatic process; but there was no kind of inequality on the
surface; neither did it give the patient any pain, except what pro-
ceeded from its mere weight. He had some brown spots on his
breast; a hardness below the fraenum penis; a raggedness and indu-
ration of the edges of the sinis of the left tonsil; a pale plumbean
countenance; and complained much of frequent pain in his knees
and elbows.

I made no scruple to inform him that he appeared to me to bel
poxed; and that I did verily believe, that the disorder in his testi-
cle arose from the same cause. I took pains to dissuade him
from submitting to any attempt toward curing his local complaint
in the testis, until he should have got rid of the disease which had
infected his whole habit, by assuring him, that if what had been
proposed to him was intended merely to let out the water, it could
not even contribute to his being made well; and that if more than
that was desired, he might probably experience more harm than
good from the attempt. Not satisfied with my opinion, he went
to Mr. Sainthill, who gave him the same kind of advice.

In a little time he applied to a gentleman well known for pro-
mising impossibilities; who told him, that this was a disease with
which the faculty were perfectly unacquainted; and if he would

A TREATISE ON THE HYDROCELE. 61

give him ten guineas, and take a lodging near him, he would un-
dertake to cure him in a week.

He made an incision of about half an inch in length, in the
very inferior part of the tumor, and let out a small quantity of
bloody water; and then applied a pledget of lint, and a piece of
sticking-plaster. The patient passed the night in a good deal of
pain, and in the morning found his testicle much swelled, and very
uneasy. He sent for his operator, who said, that this was of no
consequence, and that if he would keep quiet that day, he would
be very well the next. On the third day his testicle was so
large, so inflamed, and so painful, that he became exceedingly
alarmed, and sent for me.

I found the scrotum highly inflamed; the testicle and spermatic
process large and hard; his pain exceedingly great; his pulse hard,
full, and frequent; and his skin hot and dry. I bled him freely,
and ordered him a clyster and a lenient purge, and wrapped the
testicle up in a soft poultice. Next day, both the patient and the
parts were in the same state. I bled him again; and his clyster
and purge having thoroughly emptied him, I gave him two grains
extract, thebaic, and directed that he should take one grain every
six hours, until some ease or rest was procured. Two days were
spent before any remission of symptoms was obtained: and it was
near a fortnight, before the constant use and application of fomen-
tation, cataplasm, &.c. together with a general antiphlogistic regi-
men, and confinement to bed the whole time, had reduced the
testicle to such state as to bear examination. When it became
capable of this, it was found large and hard, but without any
water in the tunica vaginalis. His general habit being recruited
by a proper regimen, country air, and the bark, he was then
put into a mercurial course, by inunction; under which all his
other symptoms gradually disappeared, so likewise did his indu-
ration of the testicle.

CASE XVI.

A foor labouring man in Essex got a venereal hernia humo-
ralis. As his daily work would not permit him to take proper

62 A TREATISE ON THE HYDROCELE.

care of .himself, it was a considerable while before he had got rid
of his inflammatory symptoms; and when he had so done, a part of
the testicle, and the whole epididymis were left hard, and rather
too large. In getting over a high stile he missed his footstep, and
struck his scrotum with violence against the upper rail: the blow
gave him excessive pain for some minutes; but that soon ceased,
and he went on with his day's work. Next day his testicle ap-
peared swelled, and was painful to the touch; but as the man had
no subsistence but from his labour, he was obliged to follow it.
At the end of a week, he was so much worse that he could go out
no longer; and making his case known to some gentlemen, who
used to employ him, a neighbouring practitioner was desired to
visit him. A fluctuation being felt, it was supposed to be matter;
and a warm adhesive plaster was applied to forward it. In a few
days an opening was made for discharge of the supposed pus, but
nothing followed except a very small quantity of bloody serum.
The smallness of the quantity, and the nature of the fluid, joined
to the very small subsidence of the tumor, induced the surgeon to
think he had not gone deep enough; and to thrust a lancet further
in: this was attended with acute pain, and followed by a copious
haemorrhage, which was not easily restrained; or, to speak more
properly, did not soon cease. Inflammation, pain, tumefaction,
&c. followed this method of proceeding; and at the end of a week
the man was brought to St. Bartholomew's hospital.

Upon mere sight of the part, I should have supposed the case
to have been a scirrhus of the malignant kind: the testicle or scro-
tum was large, hard, unequal, of a deep red dusky colour, with
distended veins, and so painful that it could not bear the slightest
touch; and the spermatic process was far from being in a natural
or a healthy state. The man complained of constant pain in his
back; the wound discharged a bloody offensive gleet; and long
pain, and want of rest, had given him a very diseased aspect.

Nothing but the clear and circumstantial account, which both
the man and the surgeon who had attended him (and who came
with him to the hospital) gave, could have induced me to have
thought the case to be any other than what I have just mentioned:
hut they were so positive, and so consistent, that I thought myself
obliged to regard what they said, and to act accordingly.

A TREATISE ON THE HYDROCELE.

63

By phlebotomy, evacuations, anodynes, rest, a low regimen,
and the general antiphlogistic method, pursued vigorously and
long, he got a cure.

CASE XVII.

A gentleman, about thirty-seven years old, apparently in good
health, asked my advice concerning a diseased appearance in his
scrotum, for the relief of which he had come from a considerable
distance to this town.

The testicle was not much increased in size, but had lost its
equality of surface, and was craggy, and very hard; and the vas
deferens and epididymis were in the same indurated state; the
spermatic chord was somewhat varicose, but not hard; and in the
cavity of the tunica vaginalis was palpably a small quantity of
fluid. It was somewhat tender to the touch; but the pain upon
being handled was very slight, in comparison of what was felt an
hour or two after such examination: at which time, although the
pains were not constant, but rather attacked the part by intervals,
yet they were extremely acute.

He said, that he had been told that his complaint was venereal,
(to which opinion his method of life much inclined him to ad-
here,) and that he had also a beginning hydrocele. I replied, that
I wished, for his sake, that I could think so too; but that I had no.
doubt of its being a scirrhus, which would not long remain quiet.
He seemed dissatisfied; and said, that, considering the person who
had pronounced his case to be venereal was a man of character in
his profession, and whose judgment he believed was good, he
Uiought I was rather too peremptory.

I desired him to take the opinion of some people of eminence
in London, and named some to him: whether he did or not, I
know not; but in about a fortnight or three weeks, I received a
letter from him out of the country, signifying, that his friend was so
clear in his first opinion, that the case was venereal, that he had
prevailed on him to submit to a salivation for it; and that he only
now desired mv opinion concerning the best method of procuring

64 A TREATISE ON THE HYDROCELE-

it; that is, whether he should attempt it by internals, or by mercu-
rial inunction. I wrote back, that I was sorry to differ from his
friend, or to seem too tenacious of, or partial to, my own opinion,
and sincerely wished I might be mistaken; that I looked upon the
method of salivating by inunction to be in general the least fa-
tiguing or prejudicial to the constitution; and that in the case oi
particular, local induration, it certainly had the advantage of being
applied immediately to the part affected; and therefore, if I could
think that his complaint was venereal, I should undoubtedly pre-
fer the use of the ointment to every internal means; but that I
was so thoroughly satisfied that it was not, and so averse to the
use of mercury for him, that I desired him to keep that letter as
my protest against the process he was going into.

The ointment was freely used for above a month, but no alter-
ation appeared in the testicle, except that it became rather larger,
and more tender to the touch.

As the mercurial ointment happened not to affect his mouth, or
make him spit any considerable quantity, the inefficacy of it with
regard to the testicle was imputed to that; and a course of the
mercurius calcinatus, with the kermes mineral, undertaken and
followed for another month. During this, the testicle manifestly
increased in size, became more unequal, and more frequently
painful. He now came to London again; and calling on me, told
me all that had passed; but being still possessed with the venereal
idea, said that he was come hither in order to try the Lisbon diet
drink, or something of that kind.

At my request he showed his disease to Mr. Nourse and Mr.
Sainlhill, who were clear that it was not venereal, and advised
the operation. This he would not hear of at present, having got
it into his head that when every thing else had been tried, it
would always be time enough for that. During three weeks that
he staid here, he drank, by the direction of some friend, every day a
quart of strong decoction of sarsaparilla, with some of the sublimate
solution in it. The testicle continued to increase, and the sperma-
tic vein became somewhat varicose: but still there was a fair op-
portunity for extirpation. He did now indeed begin to incline to
it; but being considerably reduced in strength and flesh by what
he had taken, he would not comply with it until he had been in

A TREATISE ON THE HVDROCELE. 65

the country, and was somewhat recruited: to which I could not ob-
ject, as he then did not appear to be a fit subject for such an
operation; I mean, on account of his great reduction of strength.

At the end of two months, he came to me again. I was much
concerned to see him so much altered for the worse; he was ema-
ciated to the greatest degree; and had such a leaden paleness in
his countenance, that, had I known nothing of him, I should have
concluded that such a man had a cancer about him. He had totally
lost his appetite, and was never free from pain: his testicle was
at least twice the size as when I last had seen it, and the whole
process, quite up to the belly, large, hard, and knotty.

I would now by no means propose the operation: a consultation
of physicians was therefore had, in which the solanum was pre-
scribed. This was immediately tried, and proved here, as it has
wherever I have seen it used; that is, the patient was much dis-
ordered by it in general, and received no benefit with regard to
his disease: but as this affair happened not long after this poison
had been in a kind of vogue, it was repeated until the patient
could hardly see or hold his hand still. When this was laid aside,
recourse was had to the cicuta, which, as usual, was perfectly in-
efficacious: to it, however, a fair trial was given. And when the
poor man had thus made experiment of our most boasted specifics,
and was satisfied that no honest or judicious man would attempt
the operation, we had recourse to opium, during a few weeks that
he existed.

When dead, I examined him.

The spermatic process was thoroughly diseased, about half-way
up from the groin to the kidney; that is, it was enlarged, hard,
and very full of knots; but I did not find any apparent disease in
any other part within the abdomen.

CASE XVIII.

I received a letter from Lincolnshire, in the month of Novem-
ber, desiring to know whether that season of the year was an im-
proper one for the operation of castration, in the case of a scirr-
hous testicle; for that, if I did not, a patient labouring under such

vol. II. i

t»6 A TREATISE 0$ TttE HYDROCELE.

complaint would set out immediately upon the receipt of my an-
swer.

I wrote back, that the state and nature of the disease were of
much more consequence toward determining the propriety or im-
propriety of an operation, than the time of the year could be: and
therefore I desired either that I might have a circumstantial ac-
count of the case from some medical man, or that the patient
would come to London. In about a week I received another let-
ter, containing the following account.

That the patient was thirty-five years old; that previous to tin
appearance of the disease in the testicle, he had for some weeks
been troubled with frequent and acute pains in his back and loins;
that the testicle was considerably enlarged, indurated, and (in its
posterior part) unequal in its surface; that part of the spermatic
process, nearest to the testis, was too hard also; that the whole of
it was now perfectly free from pain; that the patient was a mar-
ried man, much subject to scorbutic eruptions and flying pains,
from the same cause; that his appetite was fallen off, and his as-
pect become pale and wan; that he had taken a considerable
quantity of the cicuta, and as much of the infusion of the solanum
as his weak state would bear; that from the former he had neither
experienced good nor harm, but that the latter had disagreed with
him extremely; that he was now determined for the operation:
and that he would be in London in a few days.

In less than a fortnight he came to me. He was extremeh
thin; and had a countenance so pale, and eyes so languid, that I
made no doubt that his nights were sleepless. His testicle was
large and hard, but perfectly equal, and perfectly indolent; the
tunica vaginalis contained a small quantity of limpid fluid; and
the vas deferens and epididymis had that kind of enlargement and
induration which frequently accompanies a hernia humoralis: but
the spermatic vessels were in a natural state, of proper size, and
free from all kind of induration. He "was so hoarse, that I could
hardly hear him speak; and so deaf, that it was as difficult to
make him hear. He complained much of frequent pains in his
shoulders and elbows, one of the latter of which was consider-
ably stiffened. The biceps muscle of the left arm was bard and
gummy; on one of his eye-brows was a large spot, with a thir

A TREATISE ON THE HYDROCELE. 6^

scab on it; and, between the scapulae, were four or five of the
same.

I told him, that I had no doubt that his deafness, hoarseness,
pains, spots, swellings, &c. were all venereal; and that I was
much inclined to believe that the complaint in his testicle pro-
ceeded from the same cause. He did as venereal patients are
frequently too apt to do; that is, he endeavoured to render my
opinion improbable, by attesting, that there had been an interval
©f some years since he had held any illicit commerce with any
woman whom he could suppose capable of injuring him; that
he had been two or three years married; had only had a slight
chancre, of which he was sure he had been well cured, &c.

I answered, that I was clear in my opinion; and would under-
take to serve him on no other principle; but desired him to take the
judgment of some other gentlemen of the profession; which he
did, and returned to me again, with an account that they thought
of his case as I had done.

The weakened reduced state in which he was, and a natural
disposition which he had to a haemoptysis, obliged me to proceed
very cautiously: his stomach would bear no medicine of the mer-
curial kind; and a very little acceleration of pulse made him hawk
up a bloody phlegm. I therefore determined upon the ointment in
small quantities, and to do in this case what I have done in simi-
lar cases several times; that is, as soon as ever the mercury raised
the pulse, or began to affect the mouth, I ordered him to take a
decoct, corticis twice or thrice a day, through the whole of the
salivation.

By these means he got rid of all his complaints, both general
and particular, and came out of his mercurial course with a more
healthy aspect, and more flesh on his bones, than he went into it.

Before I proceed to give an account of the means used for the
relief, or cure, of the hydrocele of the tunica vaginalis testis, it
may not be improper to inform the reader, that I have twice in
my life seen this disease, though in a confirmed state, and in adult
patients, disperse.

68 A TREATISE ON THE HYDROCELE-

CASE XIX.

A gentleman, about forty-five years old, consulted me on ac-
count of a swelling in his scrotum, which was not very large, but
palpably contained a fluid, and was so circumstanced in every respect,
as to prove it to be a true hydrocele of the vaginal tunic; from
which I advised him to have the water immediately drawn off.

As it was not very troublesome to him, he did not choose to have
it done then; but went away, telling me that I shoukl soon see
him again. He took the opinions of two others, both of whom
told him the same thing, and gave him the same advice.

At the end of half a year he came to me again, with the scro-
tum full, and of a pyriform figure, and so large as to be very evi-
dent through his breeches.

I would have tapped him immediately; but as he had never seen
any thing of the kind, I could not convince him that it would not
confine him the next day; and as he had some particular business
to transact in the country, he chose to go thither first, and to sub-
mit to the operation when he should return from thence.

I saw no more of him for near two months; at the end of which
time he called upon me, and showed me a scrotum perfectly empty,
and free from disease.

Taking it for granted that he had been tapped, I asked him who
had done it for him: he told me, that before he could finish the
business for which he went into the country, he was seized (for
the first time in his life) with a severe fit of the gout, which had
confined him to his bed for six weeks; during which confinement,
his swelling had gradually and totally dissipated.

I have often seen him since; and he still remains perfectly free
from all appearance of disease.

CASE XX.

A middle-aged man showed me a hydrocele of the vaginal
tunic, which had been near two years collecting, but from which

A TREATISE ON THE HYDROCELE. 69

the water had never been drawn: I advised him to have it done
soon, and he fixed on the next morning.

In his way home he got fuddled; fell down into the area of an
empty house; and in his fall struck his scrotum against a piece of
scaffolding.

In the morning early he sent for me. I found him in bed, with
,a great ecchymosis under the skin of the scrotum, which was
much swollen, and very. painful. I would have persuaded him
to have permitted me to let the water out, (thinking thereby to
to have taken off part of the tension,) but he would not consent;
and I was obliged to have recourse to fomentation, cataplasm, &c.

In about a fortnight, all the ecchymosis was dissipated, and all
the swelling from the sound side of the scrotum; and both the pa-
tient and myself thought, that the tumor from the hydrocele
was considerably less than it was before the accident. By per-
sisting in the same method for about three weeks more, the
whole of it disappeared, nor has returned since. Nor have I,
ever since, seen the same attempt succeed.

SECT. VIII.

METHODS OF CURING THE HYDROCELE OF THE VAGINAL COAT.

The methods of cure (as they are called) in this species of hy-
drocele, though various, are reducible to two; viz. the palliative,
or that which pretends only to relieve the disease in present, by
discharging the fluid; and the radical, or that which aims at a
perfect cure, without leaving a possibility of relapse. The end
of the former is accomplished by merely opening the containing
bag in such manner as to let out the water: that of the latter can-
not be obtained unless the cavity of that bag be abolished; and
no receptacle for a future accumulation left. One may be prac-
tised at all times of the patient's life, and in almost any state of
health and habit: the other lies under some restraints and prohi-

?U A TREATISE ON THE HYDROCELE.

bilious; arising from the circumstances of age, constitution, state
of the parts, &.c. &c. &c.

The palliative cure (as 1 have just observed) consists in merely
giving discharge to the fluid which is contained in, and distends,
the tunica vaginalis.

The operation by which this may be accomplished is a very
simple one. The only circumstances requiring our attention in it
are, the instrument wherewith we would perform it; and the place
or part of the tumor, into which such instrument sbould be passed

The two instruments in use are the common bleeding lancet,
and the trocar.

The former, having the finer point, may possibly pass in rather
the easier, (though the difference is hardly perceptible,) but is, in
my opinion, liable to inconveniences, to which the latter is not.
The trocar, by means of its cannula, secures the exit of the whole
fluid without a possibility of prevention; the lancet cannot. And
therefore it frequently happens, when this instrument is used,
cither that some of the water is left behind, or that some degree
of handling and squeezing is required for its expulsion; or, that the
introduction of a probe, or a director, or some such instrument,
becomes necessary for the same purpose. The former of these
may in some habits be productive of inflammation:* the latter pro-
longs what would otherwise be a short operation, and multiplies
the necessary instruments; which, in every operation in surgery,
is wrong. To which it may be added, that if any of the fluid be left
in the vaginal coat, or insinuates itself into the cells of the dartos,
the patient will have reason to think the operation imperfect, and
to fear that he shall not reap even the temporary advantage which
he expected. The place where this puncture ought to be made
is a circumstance of much more real consequence; the success of
the attempt, the ease, and even sometimes the safety of the patient,
depending upon it.

Whoever conceives, as many have done, and some still do, that
the testicle hangs loose in the middle of the water within the

* A consequence which 1 have seen to proceed from it, attended with :i
slough, of the whole dartos, and which I am much inclined to believe would
tot have happened in the same person, had the water been drawn off by ;>
'rocar-

V TREATISE ON THE HYDROCELE. "i i

vaginal coat, (like a clapper within a bell,) must also suppose that
every part of the general tumor is equally fit and proper for this
operation. The idea is erroneous, and the experiment may prove
highly mischievous. All the anterior and lateral parts of the vaginal
coat are loose and detached from the albuginea: in its posterior
and superior part these two tunics make one; consequently, the
testicle is, as it were, affixed to the posterior and superior part of
the cavity of the sac of an hydrocele; and consequently, the water
or fluid can never get quite round it. This being the state of the case,
the operation ought always to be performed on that part of the
tumor, where the two coats are at the greatest distance from each
other, and where the fluid must therefore be accumulated in the
largest quantity; and never on that part of it where the fluid cannot
possibly be. The consequence of acting otherwise must not only
produce a disappointment, by not reaching the said fluid; but
may prove, and has proved, highly and even fatally mischievous
to the patient.

It was a custom formerly, after performing this operation, to
make use of fomentations and discutient applications, upon a sup-
position that by such means a return of the disease might be pre-
vented. Among the old writers are to be found the forms of
medicines to be applied to the groin and scrotum, to prevent a
future descent of the fluid; but anatomy and experience have
proved the falsehood of such supposition, and the absurdity of such
applications: the present practitioners content themselves with a
bit of lint and a plaster; and, if the scrotum has been considerably
distended, they suspend it in a bag truss, and give the patient no
further trouble.

In most people, the orifice thus made heals in a few hours
(like that made for blood-letting); but in some habits and circum-
stances, it inflames and festers. This festering is generally su-
perficial only, and is soon quieted by any simple dressing; but it
sometimes is so considerable, and extends so deep, as to affect the
vaginal coat, and by accident produce a radical cure. I have
also seen it prove still more troublesome, and even fatal: but then
the circumstances, both of the patient and of the case, have been
particular, and such as required attention. ''See Case XXI. and
XXII.)

72 A TREATISE ON THE HYDROCELE.

Whether it arose from a fear of wounding the testicle in the
operation, or from a supposition that while the quantity was small
it was more likely to disperse, or that while there was but little
fluid, they did not think the disease sufficiently characterised, or
from some other reason which they have not thought fit to give
us; but many writers of good authority (and among them Mr. Ser-
jeant Wiseman) have forbid the puncture in an adult, while the
quantity may be supposed to be under a pint: which restriction
is still scrupulously attended to by many practitioners, to the no
small trouble and inconvenience of their patients.

When there is a sufficient quantity of fluid to keep the testicle
from the instrument, there can be no reason for deferring the dis-
charge; and the single point on which this argument ought to rest
is this: " Whether the absorbent vessels, by which the extravasa-
" tion should be prevented, are more likely to reassume their
" office, while the vaginal coat is thin, and has suffered but little
" violence from distention; or after it has been stretched and dis-
" tended to ten or perhaps twenty times its natural capacity, and
"by such distention is {like all other membranes) become thick,
" hard, and tough." For my own part, I think the probability
so much more on the side of the former, that I should never hesi-
tate a moment about letting out the water, as soon as I found that
the puncture could be made securely. And from what has hap-
pened within the small circle of my own experience, I am inclined
to believe, that if it was performed more early than it generally is,
it might sometimes prevent the return of the disease.

CASE XXI.

A gentleman, turned of sixty, came to me with an hydrocele
of the tunica vaginalis.

He was corpulent, full habited, inclined to be asthmatic, and
subject to an irregular kind of gouty inflammation, which attack-
ed different parts of him, at different times. The disease was on
the right side, the scrotum much distended, and on the skin of it was
an inflammatory kind of blush. His pulse was hard, and as I

A TREATISE ON THE HYDROCELE. 73

thought too frequent; and he seemed 10 me to have a degree of
heat and thirst not consistent with health. His age, his habit, his
general state, and what I apprehend to be the state of the sac, all
forbade any attempt but the puncture; and I took some pains to
dissuade him from that, until he should have removed both his
general complaints, and (he local inflammation on the scrotum.

He said that he felt himself perfectly well; that he was sure he
had no gout about him then; that what I took for an inflammation
on the scrotum was only a scorbutic eruption, to which he was
frequently subject; and concluded with a hint, that bethought
whatever should be done previous to letting out the water, could
be designed only for my own benefit, by lengthening the time of my
attendance.

I pierced the middle and anterior part of the scrotum with a
small trocar, and drew off near a quart of a greenish fluid; I put
a bit of lint and plaster on the orifice: and as the empty scrotum
hung very loose and flabby, I persuaded him to let it be suspend-
ed in a bag-truss.

In the afternoon he went out; and at night, finding that the
plaster was rubbed off, and thinking that the suspensory was put
on for no other reason but merely to keep the dressing on, he took
off his bandage.

Next day ho went out again, walked a good deal, drank freely
after dinner, and when he came to his lodging in the evening, he
went to bed much out of order. In the night he had a severe rigor,
for which he took a large spoonful of a tincture of snake-root and
saffron, which he always kept by him.

On the third day, finding his scrotum much swollen, and very
uneasy, he sent for me.

I found him in bed, complaining of great pain in the lower part
of his belly and groin; his pulse was quick, hard, and irregular; his
skin hot; his tongue dry, and black; his countenance flushed; and
his intellects not quite steady. His scrotum was swelled and in-
flamed all over; and in a part, considerably distant from the punc-
ture, was a moriifkd spot as big as a shilling.

After I had dressed him, I desired, as he was quite a stranger to
me, as well as to the people of the house where he lodged, that he
might have more assistance: accordingly a physician was sent for,

vor,. ir. K

T4 A TREATISE ON THE HYDROCELE.

who prescribed for him. At the end of three days one half of the
scrotum was completely mortified; and in about seven more it cast
off, with so large a portion of the tunica vaginalis, that I had no
doubt that none of it was left.

The gout now made an attack on his feet, and the inflammation
left all other parts: the sore put on a good aspect, and in a short
time he got well. But notwithstanding the very large portion of the
vaginal coat which came away in a slough, I have twice since
drawn off a full pint of water from the same side.

CASE XXH.

A man, about forty, afflicted with a large hydrocele of the tunica
vaginalis, and which, from a misapprehension of the true nature
of the disease, he had never consulted any body about, having
been robbed by a servant of a considerable sum of money, was
obliged to travel very hard, on horseback, from the neighbourhood of
Exeter, to London.

When he set out, his scrotum was free from all disease, except
its distention by the water; but when he came to this town, it was
covered all over with an inflammation of the erysipelatous kind;
was much increased in size, and very painful to the touch. He was
much fatigued with his journey; and just before he went to bed in
the evening, had a shivering, which was followed by a very rest-
less night, and a considerable degree of fever. In the morning his
scrotum was so much inflamed, that he was alarmed at the ap-
pearance, and sent for assistance. The person who came to him
immediately made an opening, by means of a pointed knife, into
the tunica vaginalis, and gave discharge to a considerable quan-
tity of water; but by night the whole scrotum was mortified. That
evening I saw him, But without any hopes of being able to serve
him. His pulse, which had been full, hard, and' rapid, was
now small and faltering; his head was very unsteady, and his
extremities cold; all the tumefaction of the scrotum was gone, and
it seemed one large eschar. On the next morning he died.

Now, though it be very possible, that the same appearance and
event might have ensued, if no puncture had been made; yet I

A TREATISE ON THE HYDROCELE. 75

think it is very clear, that it would have been more prudent to have
tried first what a soft cataplasm and an antiphlogistic method could
have done. For, by making the opening hastily, and without a pro-
per prognostic, the operator (whether deservedly or not) incurred
all the blame.

CASE XXIII.

A poor man was brought from the neighbourhood of Rosemary-
lane to St. Bartholomew's hospital.

His scrotum was of prodigious size; very hard, excessively in-
flamed quite up to his groin; it was of a dusky red colour; ex-
tremely painful to the touch; and in one part seemed inclined to
sphacelate: the spermatic process also was considerably thick-
ened. He had a hard, full, rapid pulse; a hot skin, a flushed
countenance, great thirst; and complained of most excruciating
pain in his back.

The account he gave was, that he had, for some years, been
troubled with a swelling on the right side of his scrotum, which
some of the surgeons of St Thomas's hospital had told him was
a water-rupture, and would have tapped; that he had also applied
to several rupture-doctors, each of whom had sold him a bandage,
and some of them had pretended to cure him by medicines and appli-
cations; that, finding no relief from any of these, he had a few days
before given an itinerant stage-quack three guineas to cure him.
That this operator laid hin^on his back, on a couch, and lifting
up the tumor, thrust an instrument into it. That no discharge
followed but blood. That it bled for near a quarter of an hour,
and then stopped upon his fainting away. That from the time of
this operation (which was two days) he had been in extreme pain;
and, that his operator not coming to take any care of him, his
friends had brought him to the hospital. He was immediately
bled, had a clyster injected, and the scrotum was enveloped in a
soft, warm poultice, and tied up in a bag-truss. When he had
passed a stool, I ordered him a grain of extract, thebaic, to be ta-
ken immediately, and repeated again at the distance of six or
eight hours. Next day he was much the same in every respect;

16 A TREATISE ON THE HYDROCELE.

his pain was excessive, particularly in his back, and he had not
closed his eyes. I bled him again freely, (he had two stools in
the night,) and gave him two grains of opium, and direction to
repeat one grain every six hours until he got ease and sleep. His
scrotum was well fomented, and the cataplasm continued. Two
days more were spent in this manner before we obtained any re-
mission of the symptoms: when that was done, I pierced the an-
terior part of the tumor, and drew off more than a pint of bloody
serum. The testicle now appeared very much enlarged, and
hardened; but, by persisting in the antiphlogistic method, he
at length got well.

I suppose the reade rwill have as little doubt as I have, that all
this mischief was produced by wounding the testicle, or epidi-
dymis.

CASE XXIV.

A young fellow, who was waiter at a tavern in the city, and
who had for some months past laboured under a succession of
pocky symptoms, had at last a true venereal sarcocele, with a
small quantity of fluid in the vaginal coat.

As he had several other venereal symptoms then upon him, and
his way of life subjected him to great irregularity, 1 advised him
to obtain leave to quit his place, and attend to his cure. This
he did not choose to comply with; and I heard no more of him
till about a month afterwards, when his master desired me to call
at his house.

I found the lad in bed, with a high fever, and with his scrotum
swelled and inflamed to a very great degree. He said that two
days before, he had met with an acquaintance, (a surgeon's mate
of a man of war,) who told him, that his whole complaint was a
water-rupture, and that for a bottle of claret he would cure him
immediately. That he had thrust a lancet deep into the lower part
of the swelling; that nothing followed but blood; that he had
spent some minutes in poking into it with a probe, in hopes of
getting the water out, but ineffectually; but that he had been in
racking pain ever since. Phlebotomy, clysters, opiates, febri-

A TREATISE ON THE HYDROCELE. 77

fuge medicines, &c. were all employed, by which means his pain,
fever, &c. were at length got the better of; but almost the whole
testicle cast off in one large slough.

MEANS FOR A RADICAL CURE.

Every other method of treating this kind of hydrocele, except,
the puncture, was either originally intended to obtain a radical
cure; or, having been found to have been often productive of such,
has been, by different people, ranked sometimes among the pallia-
tive, sometimes among. the radical means.

In many of the old writers are found directions for obtaining the
cure of this disease by the use of a seton, a cannula, a tent, a
caustic, a ligature, an injection, or an incision.

Some of these are adopted or preferred by one and some by ano-
ther, according to the theory which they entertained of the disor-
der, or to the benefits which they had seen to have accidental!}
arisen from the use of the said means.

To reduce these under some kind of method, (which the man-
ner of their being delivered to us does in general not very easily
admit,) we may say, that the seton, the tent, and the cannula,
were either originally meant to palliate a disease, of which the
old practitioners had very disagreeable apprehensions; or that they
were made use of upon a supposition that the fluid contained in
the cyst was in itself noxious; or that the general habit of the pa-
tient was relieved, and many other disorders prevented by the
said humour falling, or being deposited in that part; or from an
opinion that the cure of it ought not, by any means, to be hastily
or rashly attempted; that the caustic, cautery, and ligature, were
designed to prevent the supposed descent of the water from the ab-
domen into the scrotum; and, that the injection was calculated
for the constriction of a supposed breach in lymphatic vessels.

Some of these (happily for mankind) are now quite laid aside,
the reasons for their use being found to be false and groundless: of
this kind are the cautery, the ligature, and the injection. The wa-
ter is now, by every body who has made any inquiry into the mat-
ter, known to be formed and collected in the part where it is found;
and not to have fallen into it from the belly: and, though an

T8 a TREATISE ON THE HYDROCELE.

obstruction in the lymphatic vessels of the.spermatic chord, may
in some degree prevent the regular and due absorption of the fluid
from Lhc vaginal tunic, yet no breach or rupture of such vessels
can ever produce the disease in question: the extravasation, in such
ease, must be in another part; and may possibly cause a hydrocele
cf the cellular kind, in the common membrane of the spermatic
vessels, but which can never be found within the tunica vaginalis.

The reasons original !y given for the use of the the lent and the can-
nula, viz. the noxious quality of the fluid, and the necessity of a
gradual cure, are now also known and acknowledged to be without
foundation ; and therefore though these meihgds,or methods like these,
do still continue to be used, yet it is with another view, and upon
ether principles: not with intention to lengthen the time of a cure,
by making a gradual drain for the prevention of other disorders;
but merely to abolish the cavity of the tunica vaginalis, by having
excited and maintained such a degree of inflammation and suppu-
ration, as shall produce an union between that coat and the alba-
ginea testis.

This is indeed the only rational end which can, by any of these
means, be pursued: for the disorder being absolutely local, and the
tunica vaginalis (the seat of it) most commonly somewhat altered
from its natural state, by having been distended, unless the ab-
sorbent vessels can again be restored to a capacity of doing their
duty, (a circumstance which does not very often happen,) the arte-
ries will continue to exhale new serum into the cavity, and the hy-
drocele will still remain, or be renewed in a short time after each
discharge.

To obtain this end, two kinds of means are proposed: in the use
of one, it is intended, by means of a small wound, to excite such a
degree of inflammation as shall occasion, or be followed by a to-
tal and absolute cohesion of the tunica vaginalis with the tunica
albuginea. In the other, a larger and more free incision is made;
whereby the cavity of the former of these coats is'converted into a
hollow or open sore, or ulcer, to be filled up by a new incarnation;
or else, a part of the said tunic being cut away, its power of again
holding the exlravasated fluid is equally prevented.

The first, or union of the two coats, in consequence of inflamma-
tion, has sometimes been found to follow the use of such means as

A TREATISE ON THE HYDROCELE. ~9

were intended to procure only a temporary relief: it sometimes
follows the simple puncture with the trocar, or lancet. The an-
cient method of letting out the water, by a small incision, frequent-
ly produced it;' and the seton, the tent, and the cannula, though used
for another purpose, or at least for other reasons, were found to be
followed by it so often, that they soon were ranked among the
means for obtaining a radical cure.

1 This was by making, first, an incision of some length through the scrotum
and dart os, so as to lay the tunica vaginalis bare, and then by making a punc-
ture in the latter. The acounts given by Brunus and Theodoric are the same
as that of all the writers before them, and have been copied by many since :
" Curalio ejus est, ut incidatur cutis testiculorum sectione ampla secundum
" longitudinem ejus ; dein perfora, et aquam extrahe."

u Many of the old writers have left us directions *or passing the seton, and
for introducing the tent, either of lint or sponge ; and the cannula, either of
alder, or of silver.

Gulielmus e Saliceto, having first proposed the use of external applica-
tions, says, " Si hac via non consumitur aqift, tunc perfora bursam, cum
" phlebotomo tuo acuto, et extraho aquam, non subito totam, sed partem ; et
'•'• pone in foramine illo tentam lineam, vel sluppeam, autspongiam ; ut posses
" de die in diem aquam extrahere : et nota, quod hujusmodi xgritudo mul-
" totics recidivat ; et si sic, semper rede as ad perforalionem antcdictam : ct
" via ista, ct modo, perfecle curabitur."

Fabritius ab Aquapendente speaks of the tent as frequently used by him
in the mixed case of hydrocele and sarcocelc, or diseased testicle ; though,
by the account he gives of his success, it is pretty clear that he used it in the
hydrocele only, or when the testicle was not really diseased. His words are,
" Si carnosa simul et aquosa sit hernia, ego talem adhibeo curatn. Seco cutem,
" ct incisionem facio exiguam, et in loco potius altiori, quam in fundo ; inde,
" turunda imposita cum digestivo, et pus movente medicamento procedo,
' : Deque, unquam totum pus extralio, sed perpetuo bonam partem intus rc-
" linquo, quod sensim carncm corrodat, et ila sanat." An adhesion of the
vaginal coat with the albuginca may be the consequence of such treatment
of an hydrocele, and consequently such patient may obtain a radical eure;
but whoever has seen any thing of the disease properly called a sarcocelc,
will know, that it will very seldom bear such rough treatment.

This method of procuring a firm cure (by the tent) is mentioned by Ruysch:
" Sanari quidem valet id mali pertuso scroto, ope instrument! touchart dicto,
" vel lanceola phlebotomica, ut aqua vulncre exeat, sed sito plerumque re-
" crudescit malum. Si autem curationem aggrederis apcriendo scrotum a
" parte superiori ad latus, tumque vulnus turunda oblonga unguento rosaceb,
" mercurio precipitato rubro inuncto oppleveris, donee lenis mBammatio,
" eique succedens suppuratio parva, mcmbrnnulas stillantes putrefecerit,
rt tuncquc cas tenaculo eduxeris," &c.

80 A TREATISE ON THE HYDROCELE.

They were indeed (as I have already observed) originally de-
signed to discharge the water gradually; and to continue such a
drain from the parts where it had been collected, as might prevent
any of the ill consequences apprehended from the removal of the
local disorder: but the inflammation which supervened sometimes,
producing a cohesion of the sacculus to the surface of the testicle,

Professor Monro, of Edinburgh, has proposed a method of cure upon the
same principle ; but much better, and more likely to procure the one thing
aimed at, (the lenis infiammatio,) as he employs no catheretic medicines. His
words are, " Considering how readily contiguous inflamed parts grow toge-
" ther ; and how many instances there are, of people having a radical cure
" made of this hydrocele, by inflammations coming on the part; it would
" seem no unreasonable practice, to endeavour a concretion of the two coats
" of the testicle, when they are brought contiguous, after letting out the wa-
" ter through the cannula of a trocar, by artfully raising a sufficient degree of
" inflammation.

" This to be sure must be done cautiously, and so that the surgeon can
" rrasonably expect to be master of the inflammation ; and therefore the ap-
" plication of all irritating medicines, the operation of which he could not
" immediately stop, or any single mechanical effort, the effect of which he
" could not be sure of, are not to be employed.

" Suppose the cannula of the trocar was to be left in ; by the extremity of
" it rubbing against the testicle, an inflammation might be artfully raised ;
" the cause of which might be taken away as soon as the surgeon thought
■ fit," &c. Mkdical Essays.

This method, with some small alteration, I have once or twice used with
success. Being afraid of the pain which might be caused by the extremity
of the cannula rubbing against the tunica albuginea, and the irritation in con-
sequence thereof, I have left it in, but with a piece of bougie (whose
length exceeded that of the cannula about a quarter or an eighth of an
inch) within it. Of all the methods of using a tent, I think this is the best,
as the cannula secures its passage into the cavity of the vaginal coat; which
the collapsing of that tunic, and the loose texture of the dartos, would other-
wise render somewhat difficult. But although I have once or twice suc-
ceeded in this manner, I have much oftener been frustrated : sometimes it
has proved absolutely ineffectual ; and at others, I have seen it raise such a
disturbance, as to render it necessary to lay the whole cavity open before a
cure could be obtained.

Of all the methods of obtaining a radical cure of an hydrocele, by exciting
inflammation within the tunica vaginalis, and thereby obtaining an adhesion
between it and the albuginea, that by the seton is by much the best : it is the
least painful, the most easily managed, excites the least troublesome symp-
toms, and is the most frequently successful ; but, as I shall have occasion to
speak of this hereafter, I shall defer saying any more concerning it in this
place.

A TREATISE ON THE HYDROCELE. 81

what was originally calculated for a palliative remedy only, was
by many adopted for a radical one.

If the event, and consequence flowing from these means, were
as much in our power as (hey have been said to be; that is, if we
could with any tolerable precision or certainty determine the de-
gree of inflammation to be excited, and the effect of such inflam-
mation on the vaginal coat, there would be no doubt of the utility
of them: but this is far from being the case: for although it some-
times is sufficient for the purpose wished for, and rises no higher
than just to a degree equal to that purpose, yet it also frequently
happens, that either such degree and extent of it is not excited, or
it rises much higher, and proves much more painful and fatiguing,
than was promised or intended; or (as I have several limes seen,)
after a great deal of pain and confinement, a partial cohesion only
has been the consequence, and the disease has still remained, not-
withstanding all the patient's and our trouble. Sometimes the
pain, inflammation, and symptomatic fever are but little; but on
the other hand, they are all three sometimes so great as to become
alarming, at least to a patient who has been taught to expect a
cure upon much more easy terms. The whole scrotum some-
times becomes excessively inflamed; and afier a good deal of
pain and trouble, large deep sloughs are produced, and the pro-
cess becomes as irksome as any of those, whose event (with re-
gard to a cure) is much more certain.

If the inflammation be but slight, the pain and tumefaction
moderate, the symptomatic fever light, the suppuration small, and
an universal cohesion of the two membranes is produced, the event
is very fortunate, and a troublesome complaint is thereby got rid
of, upon easy terms. If the event prove what I have mentioned
in the second place; that is, if either the inflammation be confined
to the daitos, where it sometimes produces several superficial ab-
scesses (of no consequence tcvard the cure of the disease); or if
it has been so partial, as only to have occasioned the cohesiou
between the tunics of small compass, the cavity will not by this
means be abolished, nor any thing like a radical cure be obtain-
ed; consequently the patient will have undergone all the fatigue,
confinement, or pain (be it more or less) for nothing, But if he
inflammation rises high, if the scrotum swells considerably, and"

vol. n. t.

82 A TREATISE ON THE HYDROCELE.

large deep sloughs are formed, (as sometimes happens) the symp-
toms and the hazard are then fully equal to what attend those
more certain methods. Which of the three will be the event, no
man can say. Under the same external appearances, different
people are more or less liable to inflammation and fever. The
confinement of matter, in consequence of too small an opening,
Will in some habits make strange havoc, in a very short time; and
if a large opening and a plentiful suppuration must at last be sub-
mitted to, the method by a large incision at first is preferable, as
the cure is more certain, and the loss of time less. Different cir-
cumstances in the patient will render one method preferable to,
and more likely to succeed than another; but whenever a cure is
attempted by any of the before mentioned means, the uncertainty
of the event should be made known, and the patient be apprised
of what may happen, either with regard to trouble or disappoint-
ment.

All the methods hitherto taken notice of, are calculated to pro-
duce a perfect or radical cure, without making a large wound, or
bearing the appearance of a chirurgical operation: those of which
I am now to speak, are intended for the same purpose; but by
making a large and free opening into the bag containing the fluid,
to render the accomplishment of such purpose more certain.

These are called the cure by caustic, and the cure by incision.
The cure by caustic is calculated to spare the terror which a cut-
ting instrument always conveys; and (as the patrons of it say) to
avoid the painful symptoms, and hazard, which frequently attend
a large incision in these parts. The method is this: a piece of
the common paste caustic, rather less than a finger's breadth, pro-
perly secured by plaster, is applied the whole length of the ante-
rior part of the tumor, which will necessarily make an eschar of
proportional size. When this eschar either casts off, or is divided,
an opening of nearly the same length and breadth is thereby in-
tended to be made into the cavity of the tunica vaginalis testis:
by which means an opportunity is given to the surgeon to apply
such dressings to the inside of the said tunic, as shall, by the ge-
neration of new flesh, fill up, and abolish its cavity. The prefer-
ence which some practitioners have given to this method before that
by incision, has been upon a supposition that a circumstance which

A TREATISE ON THE HYDROCELE. 83

very seldom happens, will most frequently occur; I mean, the
penetration of the caustic through the vaginal tunic, containing
the fluid.

By this they hope to avoid the symptoms which are supposed to
be generally excited by the division of the said bag by a cutting
instrument. 1 will not say, that the caustic never does this; but
I must say, that I have very seldom seen it do so. If the tumor
be very large and full, the containing parts be very much on the
stress, and the skin and dartos very thin, the caustic may now and
then penetrate through, to the vaginal coat: but this, whatever
may be thought or pretended, very seldom happens; and when it
does not, the tunica vaginalis must be divided in the same state,
and manner, as if no caustic had been applied. All the differ-
ence between the two methods (caustic and incision) will then
amount to this: that in the former, the skin being mortified, the
patient is freed from a part of his apprehension at its being cut;
and the surgeon fancying that his escharotic has gone through the
vaginal coat, will divide it, as a part of the eschar: but a more
careful examination of what he is about, at the time of such opera-
tion, would generally convince the latter, that he divides the bag
unaltered by the caustic; and the symptoms which often attend
this process, confirm it. It has indeed been proposed to divide
the eschar made in the skin, down to the surface of the tunica va-
ginalis, and then, by the application of a fresh caustic, to make
an eschar in that coat also. But whoever makes, or submits to
this experiment, will find that of two evils he chooses the greater;
and to avoid the pain of incision, incurs a much greater degree
of it by the repetition of the escharotic. The pain attending the
first application of the caustic is indeed to some persons but little;
but in many it is fully equal to that of the knife, and must always
be of much longer duration. If it does not penetrate the tunica
vaginalis, that bag must be divided by a cutting instrument (as I
have already said) in the same state as if no caustic had been ap-
plied; which incision is and must be accompanied with the same
symptoms (in the same person) as in the operation by the knife
only. Nor can we at all times confine the caustic, so as that it
shall not cause a much larger sore than is intended, or can be
necessary.

$4 A TREATISE ON THE HYDROCELE.

Upon the whole, the cure by caustic, as it spares the terror
and apprehension of a bloody operation by the knife, and as it
requires no dexterity in the operator, may on those two accounts
become preferable both to many patients and surgeons; yet who-
ever promises to perform, or expects to receive, a radical cure by
caustic, upon much easier terms than by incision, will most fre-
quently be disappointed; that is, they will frequently find the fever
and inflammatory symptoms full as high, and the sore full as pain-
ful in the one as in the other; and consequently all their care and
attention to obviate mischief, full as necessary. Neither is the
accessary confinement, in general, at all less in the one than in the
other.

One of the methods made use of by the ancients, to let out the
fluid from an hydrocele of the vaginal coat was (as I have already
observed), by making a pretty large division of the scrotum and
darlos; and having by that means laid the tunic bare, to make an
opening into that also, and thereby discharge the contents. This
method sometimes produced a perfect cure in the first instance,
but much more frequently produced only a temporary relief. If
the opening made in the tunica vaginalis was small, and united
again immediately, the bag filled again with wafer, and the dis-
ease recurred; but if the orifice, instead of immediately uniting,
became inflamed, or sloughy, such an adhesion of that coat to the-
albuginea testis sometimes followed, as caused an abolition of the
cavity of the former, and consequently a radical cure. Though this
happened now and then, and the cure was really accidental, yet it
furnished a hint for attempting to attain the same end, with a
much greater degree of certainty. This was, by dividing or lay-
ing open the whole cavity or bag containing the water: and that,
sometimes; by a mere simple division of it; sometimes, by the
total removal of some part of it.

Paulus iEgineta, Albucasis, Severinus, and many others of the
best of the ancient writers, have given a particular account of this
operation: and it has at all times been practised by some, though
it has generally been decried, and dreaded. In what manner, and
with what caution it may have been executed, by those who have
given so bad an account of it, I know not; but by what I have

A TREATISE ON THE HYDROCELE. 85

seen of it, I am very confident that the ills attending it have been
idii h exaggerated; that, under proper cautions and restrictions, it
will be found to be practicable with perfect safety; and that it
ougin by no means to be laid aside. Some writers of very good
character have appeared very averse to it, and have ascribed to
it such symptoms in general, as are indeed very alarming; but
which do not occur, unless the operation be performed improperly,
or on subjects unfit for it. 1 have practised it very often, and do
not remember to have seen any ill effects from it, more than two
or three times. I would be very cautious how I advanced any
thing in a matter of this kind, which experience would not vindi-
cate, or by which others might be misled; but I have so often made
the experiment, and with such success, that I cannot hesitate to
assert, that under the necessary restraints, regarding age, habit,
state of the disease, &c. it is a very useful operation, and may be
practised with great propriety. I may, perhaps, be thought to
speak better of it than it deserves: I am not conscious that 1 do;
but I am much inclined to believe, that they, who appear so averse
to it, have either practised it on improper subjects, and impro-
per circumstances, or, having imbibed a prejudice against it, have
been unnecessarily alarmed at what would not in other cases
have alarmed them; or, that not being sufficiently apprehensive
and attentive, they have suffered their patients to get into circum-
stances of hazard, which are not justly chargeable on the opera-
tion merely, and would not happen under more careful manage-
ment.

Advanced age, an apparently bad or cachectic habit, a disposi-
tion to anasarcous or leucophlegmatic swellings, an intemperate
life, the custom of drinking spirituous liquors, and any such gene-
ral disorder in the constitution as is likely to increase the symp-
tomatic fever, which such an operation must necessarily produce,
are just objections to it: any disease of the glandular part of the
testicle, its coats or vessels, an old irreducible hernia, a diseased
state of the urethra, prostate gland, or neck of the bladder, are
(while they continue) good reasons for not performing it: but
consideratis consider andis^'m young and healthy people, and in a
recent state of the disease, this method of obtaining a radical cure
is a very good and a very practicable one.

86 A TREATISE ON THE HYDROCELE.

The method- of performing the operation is as follows: Having
appointed an assistant to grasp the upper part of the tumor, in
order to render it tense below, a puncture should be made in' the
lower and anterior part, through the skin and vaginal coat. If the
operator intends to finish the incision with a knife, he should make
this puncture large enough to admit the end of his fore-finger;
which he should introduce immediately, before the water is all
discharged, and the vaginal coat collapsed; and upon that finger
so introduced, he should continue his division of the whole length
ef the bag, and of the scrotum which covers it. If he intends to
use the probe-scissors (a more tedious and a more painful method),
he may make his first puncture with a lancet, and then introduce
his scissors. Upon the first division, the water rushes out, and
the tumor subsides: if the puncture be made small, a part of the
fluid will insinuate itself into the cells of the dartos, and by the
immediate collapsion of the vaginal coat, the operator will find
some difficulty in introducing either his finger or his instrument
into the orifice made in it; if he does not do this, he will divide
only the skin and the dartos, and the patient must undergo a second
incision, for the division of the cyst: all which inconvenience
may be avoided, by making the first opening large enough for the
introduction of the finger; and when that is in, all the rest is, upon
that, very easily executed. 1

When the vaginal tunic is divided, and the fluid thereby dis-
charged, the testicle, covered only by its tunica albuginea, comes
into view; and if the incision was either begun, or continued very
low, it generally thrusts itself out from the wound. This should
be gently replaced; and if the vaginal coat is not much thickened
by having been long distended, nothing more need be done, than

x Some practitioners, terrified at the accounts which they have received
of the operation, and yet being desirous of producing a radical cure in this
manner, have thought that they might lessen the hazard, by reducing the
size of the incision j and therefore make a very small one : but whoever
depends upon this, will find himself mistaken. An incision made one-fourth
of the length of the sac will be attended with all the trouble and hazard,
which follow one of two-thirds ; with this additional inconvenience, that the
former wjll very often prove ineffectual at last.

A TREATISE ON THE HYDROCELE. 37

to lay a small quantity of fine lint* into its cavity; and then
covering the wound with a large pledget and a soft bolster, tie the
scrotum up in a suspensory bag. This operation, if properly per-
formed, may be executed in a very few seconds: it requires no other
violence, than the mere division of the parts; and if this divison
be made with a knife, rather than scissors, it will require much
less time, and cause much less pain.

The membranous structure of the parts on which this wound is
inflicted; their continuation from the peritoneum; and the great ir-
ritability of some of those which are necessarily laid bare, and put
under a necessity of receiving dressings, must occasion pain and
symptomatic fever. This it is the business of art to moderate and
relieve: phlebotomy, lenient aperitives, febrifuges, and opiates,
will therefore become necessary. But in this case, as in many
others, it will generally be found much more easy to prevent bad
symptoms than to remove them, when they have been permitted to
attain a considerable height. The operation is, or ought to be, con-
fined to the young and the healthy, in whom inflammatory symp-
toms are most likely to occur; but (I believe I may venture to say)
to whom we have more efficacious remedies to apply in such dis-
orders, than can be used to people of a different habit, and in dif-
ferent circumstances.

The general induration of all the parts about, the thick tumid
lips of the incision, and the general inflammatory enlargement of
the scrotum, have for the first four or five days a disagreeable ap-
pearance; and may, if neglected or mistreated; prove very trou-
blesome or even hazardous; and the kind of discharge, which
during that time is made, (a thin discoloured gleet,) seems very
unequal to the reduction of so much tumefaction; but when the
febrile symptoms are appeased, and a kindly suppuration begun,
let the surgeon have patience, and not by an over-officiousness, or
by improper dressings, interrupt nature in what she is about: let
him, by warm fomentations, keep the parts clean and perspirable;
let him dress the wound with a small quantity of soft, easy, di-

y By no means to fill, or distend it, or to make any pressure on the testi-
cle : whose tunica albuginea is very irritable, as well as acutely sensible.

88 A TREATISE ON THE HYDROCELE.

gestive applications; and covering the whole scrotum 2 with a soft,
warm pouhice, suspend it in a proptr bag; and he will in general,
soon see a favourable change in all the appearances; he will see
the inflammation disappear, the tumor resolve, and all the tume-
faction in due time subside. But if he neglects these general
cautions, and under a notion of assisting digestion, goes to work
with precipitate and other irritating dressings, the face of things
will not be so agreeable; the tumor will not subside; and he will
continue, or rather create, a painful, undigested sore, with all its
consequences; but, for which, he only is accountable.*

z The impalpable farina seminislini, put into boiling' water, with a proper
quantity of ung. sambuc, fresh butter, or lard, is the easiest made, and is the
neatest, softest, smoothest, and most relaxing* application of the kind ; has
nothing offensive in its flavour ; nor is it, like most other cataplasms, like!}
to excite a herpes.

a The great hardness which almost always attends inflammations of these
parts, has (I suppose) been the reason, why so many writers have advised,
and so practitioners still use such applications,'as (though really cscharoiics
are called dissolvers of induration, and removers of obstruction.

I would be very cautious how I made objection to what so many have re-
commended; and, in a matter of mere speculation, would rather doubt my
own judgment, than that of some others : but this is a fact, of which I have
too often been convinced to be mistaken ; and, therefore, I cannot help say-
ing, that it appears to me, that all applications of this kind, even in the mild-
est of them (die red precipitate) are generally very improperly used; that
they give unnecessary pain ; and retard, what they are used with design to
expedite.

Inflammatory hardness and tumefaction is not peculiar to the scrotum,
upon its being wounded : it is common to all parts of similar structure ; that
is, the adipose and cellular membrane all over the body.

When such parts are irritated by a large wound, they cannot resist a sud-
den influx ; the consequence of which must, for a time, be obstruction, in-
duration, and swelling : but one moment's reflexion on the natural structure
and state of these parts, before such wound was inflicted, or such irritation
excited, will prove that ease, relaxation, and free suppuration, must be the
intentions proper to be pursued; and that every application, winch either
stimulates, gives pain, or corrodes, must pervert and counteract such inden-
tions. .

The breasts of women, the axillx of both sexes, the parts surrounding the
intestinum rectum, the cellular membrane in the perinauim, under the in-
teguments of the penis, and in several other parts of the body, are liable to
this kind of alteration, when injured ; but* this induration is very unlike to a
glandular one, and requires very different treatment. In the latter, a

A TREATISE ON THE HYDROCELE. 89

In about six weeks, the scrotum is generally reduced to nearly
Us natural size; and when the wound is quite healed, the cicatrix
is a mere line, corresponding to the original incision; which is a

destruction of parts is sometimes necessary, and escharotic medicines may
therefore be required. But in the former, mere relaxation is all that is
wanted: whatever gives ease, and appeases the inflammatory tension, will
best produce matter, and answer the purpose Which ought to be aimed at.

The most convincing proof of the truth of this doctrine may be drawn
from that case, which, of all those which affect this kind of membrane, is
generally the most troublesome ; I mean the fistulae in perinaeo. In these
the induration and enlargement of the parts are sometimes so great, as to be
very alarming; hard callous e^rescences; deep and long sinuses, with
small orifices; constant pain and irritation, from the lodgement of matter and
urine ; a symptomatic fever of the hectic kind ; and a difficulty either of re-
taining the urine within, or expelling it from the bladder, make a part of the
most frequent characteristics of this disease ; and yet, even these cases,
terrible as they are, do frequently admit relief, and are sometimes even
cured, without any destruction of parts, or the use of any one escharotic ap-
plication : a free division of all the hollow and hard parts ; the application
of soft, easy digestives, and of a warm, relaxing poultice ; a total abstinence
from all such external remedies as corrode or irritate ; and all such internal
ones as, under the title of deobstruents, increase the velocity of the circu-
lation, and waste the patient's strength, by watching, purging, and sweat-
ing; and an easy and gradual distention of the urethra, by a simple unmedi-
tated bougie ; will, in some instances (indeed, in all, where any good can be
done at all) remove most of these disagreeable circumstances and appear-
ances : in which cases, a kindly suppuration will be afforded by all the di-
vided parts ; a florid, well conditioned incarnation will be the consequence;
the cicatrix will be small, soft, and moveable, and very unlike to what
must follow from the use of catheretic applications.

This is really a matter of much greater general importance, than it is sup-
posed to be : the symptomatic fevers, which are either produced or main-
tained by the injudicious application of painful dressing, are much more fre-
quent than they are thought to be : not to mention the loss of time which
they must always cause, and the very disagreeable deformities they often
occasion.

The surgery of most of our forefathers was coarse and rough ; and many
of the practitioners affected a kind of brutal, unfeeling rusticity. The old
maxim, " Dolor medicinadoloris," was so generally received, that the surgeon
almost forgot his patient's sensation; and the common people thought they
were neglected, if they were not tortured. Lord Bacon's most excellent
advice, " Inveniend umquid nature ferat aut faciat," was but half remem-
bered; they tried very sufficiently what nature would bear, but very seldom
Sad patience to know what she could do. Under a mistaken notion of going
VOX,. IT. M

90 A TREATISE ON THE HYDROCELE.

circumstance of more consequence to the patient than is ima-
gined, especially if he be obliged to get his bread by labour.

If the tunica vaginalis, containing the water, by long or frequent
distention; or from any other cause is become thick and hard, and
cannot therefore contract itself, or be contracted, upon the evacua-
tion of the fluid; it will contribute considerably to the thickness of
the lips of the wound, as well as to their hardness, pain, and diffi-
culty of digestion. In this case, the best way is to remove a par!
Of it, on each side, at the time of the operation. The cellular
btructure of the dartos easily admits this to be done; and when
these sides are thus taken away, the lips of the wound consist on-
ly of the common integuments. A knife will do this with much
more ease and expedition than any other instrument whatever.
The method proposed by the late Mr. Douglas, of doing it by re-
peated snips of the probe-scissors,' is operose, unhandy, and unne-

*to the bottom of wounds and abscesses, and of dissolving indurations, they
crammed and distended the cavities, and corroded and irritated their sides,
till a train of bad symptoms were often excited, which the original disease
had no share in the production of.

That this is no exaggeration, let their works testify ; and that something
of this kind is still too much in use is too well known. All dressings are in
fact extraneous bodies ; and when they either consist of such materials as
give pain, and excite irritation, or are crammed in with injudicious violence,
they are foreign bodies, with other mischievous qualities annexed. "Where
destruction of parts is necessary, the sooner it is executed the better, and
the necessary pain must be complied with ; but in the application of dress-
ings to the inside of abscesses, to hollows made by the removal of diseased
parts, to large sores attended with hardness and inflammation of the com-
mon membrane : in short, wherever mere suppuration is required, they
cannot be too light, soft, and easy; all that we have to do is, not to obstruct
nature in the execution of those offices, to which she is generally fully
equal ; in which we can lend her no assistance beyond removing impedi-
ments out of her way. In the particular case of the divided tunica vaginalis,
that degree of thickness and hardness, which it sometimes acquires by long
distention, is urged as a reason for the use of caustic applications : but
this is a method of reasoning to which I cannot agree, having often expe-
rienced the contrary. That membrane, like all others of the exanguiou?
kind, is difficult and slow of digestion, especially if altered by disease; but
that it will in time become sloughy, digest, and yield a kindly suppuration
and incarnation, by the mere use of simple, easy applications, and without
that of any escharotic, (not even the red precipitate,) I have often and often
' xperienccd

A TREATISE ON THE HYDROCELE. 91

cessarily painful and tedious: nor is the cutting away an oval
piece of the scrotum, as advised by that gentleman and some others,
at all necessary: on the contrary, the more loose that part of the
scrotum is, which is to cover the testicle, (now deprived of its vagi-
nal coat,) the better; as it will be more capable of corrugation.

With these cautions, and under the proper restrictions already
mentioned, this method of obtaining a radical cure is very practi-
cable. That it is sometimes accompanied by troublesome symp-
toms is beyond all doubt; and so is the method by caustic. I
cannot say, that I have never seen it prove fatal; nor can that be
said of any operation of consequence. Much depends on the
choice of a proper subject, and the observance of the necessary
means and cautions; without which, both this, and the use of the
caustic, will always be troublesome, and sometimes hazardous.

Before I finish the account of this method of cure, I would take
the liberty of mentioning one circumstance more, which appears to
me to be of consequence. When the quantity of fluid is large,
and the scrotum and tunic much on the stretch, I think it is better
to discharge the water by mere puncture; and not to perform the
operation for the radical cure, until a fresh accumulation has again
moderately distended it. The inflammation necessarily conse-
quent upon the division of these parts, just after they have been
so much on the stretch, and so suddenly let loose, may be (and I
think I might say, that I have seen it prove) productive of worse
symptoms, and a higher degree of fever and tumefaction, than
usually occurs when the same parts are divided in a less distended
state.

This method of obtaining a radical cure by incision, of which
I- have given the fairest and most impartial account in my power,
must always be considered as a matter of choice, and never can
be an operation of necessity; that is, they who are afflicted with
the disease, for whose cure it is calculated, will always have it in
their power to be temporarily relieved by the palliative means, or
may make trial of any of the above mentioned less certain at-
tempts, without incurring any, or a very small degree of hazard.
Now as this method can never be said to be totally and absolutely
void of some danger; as it bears the appearance of an operation of
some severity; and as it must always be voluntarily and deliber*

92 A TREATISE ON THE HYDROCELE.

ately submitted to, without any real necessity from the circum-
stances of the disease; in other words, as it must be chosen by
the patient, merely to avoid the trouble and inconveniences Vat-
tending the disorder, and not necessarily applied to, as some other
operations are, to save or preserve life, it does not often happen
that we are railed upon to practise it. b

The number of people labouring under this disease, and who
come within the above mentioned necessary restraints, from age,
habit, manner of living, date of the complaint, thickness of sac,
&c. &c. &c. is great. And that of those, who either have an in-
superable dread of an operation, or are so circumstanced or con-
nected in life, as to make any such degree of danger highly impro-
per to be voluntarily incurred, is still greater: so that by far the
majority of those who are afflicted with the disorder, are obliged
(however irksome it may be, or however disagreeable it may
prove to them) to carry it through their life, seeking relief now
and then from the palliative remedy of tapping. This renders it,
to the active and to the laborious, a complaint of more conse-
quence than is generally imagined.

From these considerations, I have often been induced to think
seriously on the subject, and to make many experiments; the re-
sult of which, when likely to prove at all useful to mankind, or
creditable to the art of surgery, I shall always think myself oblig-
ed to communicate.

Every practicable method proposed by the ancients I have tried;

b The method of cure of the hydrocele by incision, which Mr. Pott has
here so fully described, he did not perform during the last twenty years of
his life; on the contrary, in every conversation, public and private, repre-
sented it as a severe and unnecessary operation ; during- which time it has
not been performed at St. Bartholomew's hospital. Before that period it
was the usual practice.

As this disease has of late been the subject of so much disquisition, and so
many improvements have taken place in the treatment of it, I had entertain-
ed hopes that the operations by incision and excision would have been
wholly laid aside, as I must confess they always appeared to me painful in the
execution, and productive of great and dangerous inflammation, often caus-
ing a fever which put the life of the patient in considerable hazard. Mr.
Cheselden, who was by no means a timid operator, speaking of the cure of
the hydrocele by incision, says, " This I have done, and seen done several
1 times ; but never thought the cure worth the trouble and pain the patient
•"•' underwent." — E.

A TREATISE ON THE HYDROCELE. 93

and have found them in general painful, fatiguing, hazardous, or
inefficacious.

The tent, whether of lint or sponge, is subject to great objec-
tions, both in its first application, and its future necessary con-
tinuance. The cellular structure of the dartos, and the loose con-
nexion between the skin and tunica vaginalis, render its intro-
duction (unless a cannula be used) sometimes difficult. When
in, great care must be taken to keep it there for some time, or
the effect intended (an inflammation of the vaginal coat and al-
buginea) cannot be obtained; and the means made use of for its
distention, as well as the nature of the tent itself, (especially if
made of sponge,) prove frequently very fatiguing, not to say mis-
chievous, by the irritation and the necessary confinement of the
matter. And, after all, I have several times seen it produce on-
ly a partial cohesion; and that so small an one, as to prove no
cure at all, nor at all prevent the future accumulation of water, o»
the necessity of frequent tapping.

The cannula, when used for the same purpose instead of a
tent, is indeed easily introduced; and when in does not confiiu
the matter: but then its hardness, inflexibility, and thin edge, and
the absolute impossibility of directing or managing it in the fre-
quent and necessary motions of the patient, though confined to his
bed, render it a 5 very unpleasant and troublesome guest within the
tunica vaginalis; and if, to avoid this inconvenience, a piece of
bougie be kept within it, this, while it is there, confines, what
ought to be discharged.

The point to be aimed at is, to excite such a degree of inflam-
mation, both in the tunica vaginalis and tunica albuginea, as shall
occasion a general and perfect cohesion between them: and this,
if possible, without the production of slough or abscess; without
the hazard of gangrene; and without that degree of symptomatic
fever which now and then attends both the caustic and the inci-
sion; and which, when it does happen, is so alarming both to
patient and surgeon.

These ends I have frequently obtained, by the use of a seton.
It is a method of cure mentioned by Aquapendens, as used b\
Guido, and others before him (though their process was somewhat
different from mine). I have several times tried it on subjects of

94 A TREATISE ON THE HYDROCELE.

very different ages, some of them more than fifty years old. It
requires confinement to bed only for a few days; after which, the
patient may lay on a couch to the end of the attendance; which
is generally finished in about three weeks, or a month at the far-
thest: and, during all that time, no' other process or regimen is
necessary, than what an inflammation of the same part from any
other cause (for example, a hernia humoralis) would require. But
for a more particular account of this I must refer the reader to the
tract on this subject, which he will find at the end of the present.

SECT. IX.

THE HEMATOCELE, OR TUMOR FROM BLOOD.

This is a swelling of the scrotum, or of the spermatic process,
proceeding from, or caused by blood; and though spoken of by
writers as one simple disease, is liable to so considerable variety,
both with regard to nature and situation, as to admit, or even
require, being divided into several kinds.

Such distinction of the different kinds of haematocele, though
not usually made, is absolutely necessary toward rightly under-
standing the disease; the general idea or conception of which
appears to me to be somewhat erroneous, and to have produced
a prognostic which is ill founded, and hasty. According to my
conception and experience in this matter, the disease, properly
called haematocele, is of four kinds; two of which have their seat
within the tunica vaginalis testis; one within the albuginea; and
the fourth in the tunica communis, or common cellular membrane,
investing the spermatic vessels.

In passing an instrument, in order to let out the water from an
hydrocele of the vaginal coat, a vessel is sometimes wounded;
which is of such size as to tinge the fluid pretty deeply at the
time of its running out. The orifice becoming close, when the
water is all discharged, and a plaster being applied, the blood

A TREATISE ON THE HYDROCELE. 9o

ceases to flow from thence, but insinuates itself partly into the
cavity of the vaginal coat, and partly into the cells of the dartos;
making, sometimes, in the space of a few hours, a tumor nearly
equal in size to the original hydrocele. — This is one species.

It sometimes happens, in tapping an hydrocele, that although
the fluid discharged by that operation be perfectly clear and
limpid, yet, in a very short space of time (sometimes in a few-
hours) the scrotum becomes as large as it was before, and palpa-
bly as full of a fluid. If a new puncture be now made, the dis-
charge instead of being limpid (as before) is now either pure blood,
or very bloody. — This is another species; but, like the preceding,
confined to the tunica vaginalis.

The whole vascular compages of the testicle is sometimes very
much enlarged, and at the same time rendered so lax and loose,
that the tumor produced thereby has, to the fingers of an examiner,
very much the appearance of a swelling composed of a mere fluid,
supposed to be somewhat thick or viscid. This is in some mea-
sure a deception; but not totally so: the greater part of the tume-
faction is caused by the loosened texture of the testis; but there is
very frequently a quantity of extravasated blood also.

If this be supposed to be an hydrocele, and pierced, the discharge
will be mere blood. — This is a third kind of hematocele; and
very different, in all its circumstances, from the two preceding:
the fluid is shed from the vessels of the glandular part of the testi-
cle, and contained within the tunica albuginea.

The fourth consists in a rupture of, and an effusion of blood
from, a branch of the spermatic vein, in its passage from the groin
to the testicle. In which case, the extravasation is made into the
tunica communis, or cellular membrane investing the spermatic
vessels.

Each of these four I have seen so distinctly and perfectly, that
I have not the smallest doubt concerning their existence and of
their difference from each other.

The tunica vaginalis testis, in a natural and healthy state, is a
membrane, which, although firm, is of no great thickness.; it is
white, or rather of a reddish white colour; and its blood-vessels
arc (in a healthy state) no more apparent to the eye, than are those of
the tunica albuginea* but when it has been long or much distended,

96 A TREATISE OK THE HVUKOCKLL.

it thereby becomes thick, and tough; and the vessels (especially
those of its inner surface) are sometimes so large as to be very
visible, and even varicous. If one of these lies in the way of the
instrument, wherewith the palliative cure is performed, it is some-
limes wounded: in which case, as I have already observed, the
first part of the serum which is discharged is pretty deeply tinged
with blood.

Upon the collapsion of the membranes, and of the empty bag,
this kind of haemorrhage generally ceases, and nothing more comes
of it-. But it sometimes happens, either from the toughness of the
tunic, or from the varicous state of the vessel, that the wound (es-
pecially if made by a lancet) does not immediately unite; but con-
tinues to discharge blood into the cavity of the said tunic, thereby
producing a new tumor, and a fresh necessity of operation.

This is what I have taken the liberty to call the first species of
hxmatocele, and plainly and evidently consists in a wound of a
vessel of the vaginal tunic.

Upon the sudden discharge of the fluid, from the bag of an over-
stretched hydrocele, and thereby removing all counter-pressure
against the sides of the vessels, some of which are become vari-
eous, one of them will, sometimes, without having been wounded,
burst. If the quantity of blood shed from the vessel so burst be
small, it is soon absorbed again, and, creating no trouble, the thing
is not known. c But if the quantity be considerable, it, like the pre-
ceding, occasions a new tumor, and calls for a repetition of the
operation. This I call the second species: which, like the first,
belongs entirely to the vaginal coat, and has no concern either with
the testicle, or with the spermatic vessels. In both, the bag which
was full of water, becomes in a short space of time distended with
blood ; which blood, if not carried off by absorption must be discharged

c From this cause it very often happens, that the last running (if I may use
the phrase) of the water from an hydrocele, is bloody (all the former part
having been perfectly clear) ; and from hence it is, that a bloody discharge
may almost always be produced upon the same occasion, by pressing and
handling the scrotum. They who would see a very ingenious account of this
kind of hxmatocele, and a very probable application of the same principle,
for the solution of some other appearances in diseases, may find it in the
Edinburgh Essays from Professor Monro, the father.

A TREATISE ON THE HYDROCELE. 91

by opening the containing cyst; but in neither of these can cas-
tration (though said to be the only remedy) be ever necessary: the
mere division of the sacculus, d and the application of dry lint to its
inside, will in general, if not always, restrain the haemorrhage, and
answer every purpose, for which so severe a remedy has been pre-
scribed. The other two are indeed of more consequence: thev
interest either the testicle itself, or the vessels by which it is sup-
plied with blood, and rendered capable of executing its office; and
are sometimes not curable, but by removal of the part.

One of these is seated within the tunica albuginea of the testicle;
the other in the tunica communis of its vessels: they are neither
of them very frequent; but when they do happen, they call for alj
our attention.

If blood be extravasated within the tunica albuginea, or proper
coat of the testicle, in consequence of a great relaxation, and
(as it were) dissolution of part of the vascular compages of that
gland, and the quantity be considerable, it will afford or produce a
fluctuation, to the hand of an examiner, very like to that of an
hydrocele of the tunica vaginalis; allowing something for the diffe-
rent density of the different fluids, and the greater depth of the for-
mer from the surface.

d It may Indeed happen, that the blood of the patient may be in such slate,
as to be incapable of coagulation : in which case, the haemorrhage will con-
tinue from the inside of the sac, although it be laid open ; and also from alt
the divided parts. This circumstance, though a very hazardous one, cannot
be foreseen ; nor do I know, in this slate of the juices, what benefit can arise
from the removal of the testicle ; for the haemorrhage will certainly b.- con-
tinued, from all parts of the wound necessary in such operation, upon the
same principle, and for the same reason that it could not be restrained from
the inside of the sac. Such an indisposition of blood is often, in cachectic
habits, the cause of very troublesome and fatal haemorrhages, at some distance
of time from amputation, as well as immediately. If this want of an agglu-
tinant quality in the blood is not corrected, or is not capable of correction, it
generally goes hard with the patient, let the operation be what or where it
may : for it is not merely the suppression of the bleeding that is required
the same ill quality of blood will prevent suppuration, produce bloody,
sanious gleeting, gangrene, and mortification. This is an evil, of which every
practitioner must have seen fo many instances, that it is needless to produce
particular ones

VOL. TI N

118 A TREATISE ON THE HYDROCELE.

If this be mistaken for a simple hydrocele, and an opening be
made, the discharge will be blood; not fluid, or very thin; not
like to blood circulating through its proper vessels; but dark, and
dusky in colour, and nearly of (he consistence of thin chocolate
(like to what is most frequently found in the imperforate vagina).
The quantity discharged will be much smaller than was expected
from the size of the tumour; which size will not be considerably
diminished. When this small quantity of blood has been so drawn
off, the testicle will, upon examination, be found to be much larger
than it ought to be; as well as much more loose and flabby; instead
of that roundness and resistance arising from a healthy state of the
gland, within its firm strong coat: it is soft, and capable of being
compressed almost flat, and that generally without any of that
pain and uneasiness which always attend the compression of a
sound testicle. If the bleeding ceases upon the withdrawing the
cannula, (supposing a trocar to have been used,) and the puncture
closes, a fresh accumulation of the same kind of fluid is soon made,
and the same degree of tumefaction is produced, as before the ope-
ration: if the orifice does not close, the haemorrhage continues, and
very soon becomes alarming.

In the two preceding species, the blood comes from the tunica
vaginalis, the testis itself being safe and unconcerned; and the re-
medy is found, by opening the cavity of the said tunic: but in tbrs,
the haemorrhage comes from the substance of the testicle; from the
convolutions of the spermatic artery, within the tunica albuginea.
The division of the vaginal coat can here do no good;, and an in-
cision made into the albuginea can only increase the mischief: the
testicle is spoiled, or rendered useless, by that kind, of alteration
made in it, previous to the extravasation; and castration is the
only cure, which a patient in such circumstances can depend
upon.

The last species of this disease arises from a bursting of a
branch of the spermatic vein, between the groin and scrotum, in
what is generally known by the name of the spermatic process.
This, which is generally produced by great or sudden exertions of
strength, feats of agility, &c. may happen to persons in the best
health, whose blood and juices are in the best order, and whose
genital parts are free from blemish or disease

A TREATISE ON THE HYDROCELE. 99

The effusion, or extravasation is made into the cellular mem-
brane, which invests and envelopes the spermatic vessels, and
has something the appearance of a true hernia. When the case
is clear, and the extravasated blood does not give way to discu-
ticnt applications, the only remedy is to lay the tumor fairly open,
through its whole length. If the vessel or breach be small, the
haemorrhage may be restrained by mere compression with dry lint,
or by the use of styptics; but if it be large, and these means do
not succeed, the ligature must be made use of. If the bleeding
branch can be tied singly, the testicle may be preserved; if it can-
not, and the whole spermatic process must be included, it is un-
necessary to add, that the testicle must be removed.

CASE XXV.

A healthy man, about thirty years old, desired me to let out
the water from an hydrocele; which operation he said, had, for
some time past, been performed upon him, twice a year, by the
late Mr. Bell, of Red-lion-square; and he desired also that I would
do it with a lancet. I let out near a pint, the first part of which
was deeply tinged with blood; but as it ran, it became clearer and
clearer, and at last was perfectly limpid; and when I put on the
plaster, he did not bleed a drop. The next morning he came to
me again; told me that he had bled a good deal in the night; and
showed me his linen, which was very bioody. As there was no
discharge at this time, I only renewed his plaster, put him a bag-
truss on, and desired that he would go home and keep quiet.
He remained free from haemorrhage for some hours, and there-
fore neglecting my last caution, he walked about a good deal, and
heated himself, and the next day sent for me to look at his scro-
tum, which was large and full. Making no doubt, from all the
circumstances, that the tumefaction was from blood, I told him
my opinion; and at the same time advised, if it did not dissipate
by proper attempts for that purpose, to submit to have the vaginal
coat laid open, and thereby obtain a radical cure.

Some time was spent ir» attempting discussion; during which

100 A TREATISE ON THE HYDROCELE.

the tumor increased, and he now and then bled pretty freely from

the orifice, which became spongy, and would not heal.

Finding all endeavours ineffectual, he submitted: the tunica
vaginalis was laid open; a considerable quantity of blood was dis-
charged (some in a fluid state, but principally grumous;) he had
no disagreeable symptoms, and, in about six weeks, was perfectly
well.

CASE XXVI.

An elderly man, who had often had a large hydrocele tapped
at the hospital, came one day, as usual: I made a puncture with
a lancet, and let out the water; but was near half an hour before
I could stop an haemorrhage from the wound.

The next clay he came again, and complained to one of my
dressers, that he had bled, more or less, all the night. He was
properly dresssed; the bleeding restrained; and he was advised to
go home, and keep quiet upon the bed.

The third day, when I was again at the hospital, he came and
showed me his scrotum; which was as full, and as large, as when
I first tapped it: the orifice was not healed; and, upon pressure,
blood was discharged from it. He said, that he could not afford
to rest from his labour; and my week for accidents being expired,
Mr. Crane took him under his care.

He (finding the bloody discharge still continued, notwithstand-
ing the man kept in bed, and was properly taken care of) made a
free incision into the tumor; turned out a good deal of coagulated
blood with bis finger; and then, lightly filling the cavity with lint,
obtained a suppression of the haemorrhage, and produced a radical
cure.

CASE XXVII.

A gentleman who used to come to London about every five or
six months, to have a large hydrocele emptied, came to me under
a great alarm.

A TREATISE ON THE HYDROCELE. 101

Having often had the water drawn off by puncture in London,
he determined to let the apothecary of the village where he lived
do it for him, and thereby save him the trouble of a journey. The
operation was very properly performed, and the bag perfectly
emptied: but the next morning, to his great astonishment, he found
it as full as before. His apothecary was as much surprised as
himself; and the patient got into a post-chaise, and came imme-
diately to London.

Upon hearing this account, and seeing and feeling (he tumor,
I made no scruple of declaring it to be bloody; and that if it did
not soon dissipate by rest, and proper applications, it must certain-
ly be let out.

All attempts for dispersion proved fruitless, the tumor increased,
and as his health and habit were good, and his age by no means
advanced, I advised him to submit to an incision; by which I
hoped that he would not only get rid of the present evil, but
would most probably obtain a radical cure. He complied, upon
condition, that I would first by puncture satisfy him, that I was
right in my conjecture with regard to the contents.

I passed a lancet into the fore-part, and gave discharge to a
clear blood: while that was running out, I made, by means of a
probe-pointed knife, an incision of sufficient size to admit a dos-
sil or two of fine lint. For a day or two, the symptoms were un-
towardly, and the discharge was large, and bloody; but by pro-
per care, keeping very quiet, and taking freely of the bark with
elixir vitrioli, every thing ended well.

CASE XXVIII.

A lusty, healthy man, about forty, who had the care of a ma-
nufacturer's warehouse in my neighbourhood, consulted me on
account of a large hydrocele of the tunica vaginalis. The tumor
was very large, the parts considerably on the stretch, and I advis-
ed him to have it tapped directly.

About twenty ounces of clear water were drawn off by means
of a trocar, without the appearance of a drop of blood. As he had
carried his burthen long, and had never been relieved from it be-

102 A TREATISE ON THK HYDROCELE.

fore, he was much surprised at this immediate ease, and went lo
work as soon as lie got home.

The next morning lie came to me much alarmed, and showed
me his scrotum; which was full half as big as before the punc-
ture had bcui made. I had no doubt that its present contents
was blood;, and was very apprehensive that it might require the
same treatment as the preceding ease: which, in his constitution,
and manner of living, must have been attended with hazard.

I ordered him home to bed immediately, took some blood from
his arm, and directed a cooling purge to be taken the next morn-
ing; the scrotum was suspended, and wrapped in a rag folded seven
or eight times, and wetted in a solution of sal. amnion, crud. in
vinegar and water, and he had direction to keep it constantly wet.
On the third day I bled him again, and ordered him another
purge for the fourth, and continued the same application.

finding the swelling quite at a stand, and imagining that by
mending his state of blood, a further effusion might possibly be
prevented, and an opportunity given for the absorption of what
was already shed, I advised him to take a dram of the cortex
every six hours: this he did for as many days; during which, the
tumor visibly lessened: and, by persisting in the same method, he
got well: that is, all that degree of tumefaction, which I suppose
to have been caused by blood, disappeared. After some months
the scrotum became large again; and he followed the advice
which I had given him: viz. to have the fluid drawn off, before it
attained too- large a size. I have several times since tapped it,
and have always drawn off a clear fluid.

CASE XXIX.

A man, about forty-seven, of a sallow complexion, and subject
to colicky complaints, had the water drawn off from an hydrocele
of the vaginal coat, by means of a small trocar. The quantity
was near a pint; and the bag was perfectly emptied. The next
morning it seemed to contain a fluid, although in no great quan-
tity: he showed it to the person who tapped him the day before,
and who advised him to put on a bag-truss, and to take a smart

A TREATISE ON THE HYDROCELE. 103

purge. In three days it was so manifestly increased, as to alarm
the patient, aiul make him desirous of further advice.*

On the sixth day from the first operation, I saw him, and found
the scrotum so much enlarged, that I made no doubt the vaginal
tunic contained at least seven ounces, which I suspected to be
blood.

I advised a discutient application, and the free use of the cor-
tex; but this did not suit the humor, either of the patient or of his
surgeon. lie took three or four purges of rad. jalap, and made
use of a warm fomentation. At the end of about a month, I was
desired to see him again. The tumor was larger, and his strength
impaired by his purging. It appeared to me to be now of such a
size, and in such state, that nothing but the operation could serve
him; and for which I prepared him, if the puncture should pro-
duce a discharge of blood only. An opening was made with a
lancet, and the discharge was clear fluid blood: I would have pro-
ceeded, but the patient would not permit mc: and he was dressed
with a superficial pledget, and a plaster.

Blood oozed from the orifice all that night, and part of the next
day; and when I saw him again, he could not have lost less than
a pint.

I was well aware, what might be the consequence of a division
of the tunica vaginalis, in such a habit; but, at the same time, it
seemed to be the unicum remedium, for he would take no medi-
cine. The haemorrhage continuing another day, he submitted.
The operation discovered no one bleeding vessel; nor did I ima-
gine that it would, being convinced that it came from the inside
of the tunic. He was dressed with dry lint, and put to bed with
an opiate. All that night, and the succeeding day, the discharge
was large and bloody: and the lips of the incision, on the second,
were flabby, and free from inflammatory tumefaction. I told him
my opinion freely, and pressed him to take the bark, or have
more assistance; both which, at that time, he refused to do.

On the close of the third day, the haemorrhage still continuing,
he becoming sick and faint, and his pulse failing a little, he was
alarmed, and permitted us to direct for him. A draught, eonsist-
ing of a dram of bark, half a dram of confect. cardiac, and three
or four drops of tinct. thebaic, was ordered in be taken every four
hours

104 A TREATISE ON THE HYDROCELE.

Not to make the account tedious, by a relation of every minute
circumstance, he persisted in this method, and it was four days be-
fore the bleeding ceased, or the edges of the incision became in-
flamed, or showed any tendency toward the suppuration. But at
last, with some difficulty, he got well.

CASE XXX.

A labouring man, who had fallen down in the street with a
load on his back, was brought into St. Bartholomew's hospital,
on a suspicion of his having got a rupture, in consequence of his
fall; he having immediately perceived a swelling in his groin and
scrotum, which he had not before.

The tumor seemed to occupy the whole spermatic process;
which was so enlarged by it, that it was impossible to feel the
passage of it from the abdomen, through the muscle: but the tes-
ticle below it was perfectly distinct.

The appearance of a tumor, the suddenness of its formation,
the distinct situation of the testicle below, and an accidental cir-
cumstance of the man's not having had a stool for two days past,
inclined Mr. Freke (whose week it was) to believe it to be, and
to treat it as, a rupture. He made some attempts for reduction;
and, finding them fruitless, determined upon the operation imme-
diately.

He divided the skin and membrana adiposa, down to what he
took to be the hernial sac; and when he had so done, had a mind
to endeavour at the return of the intestine, without opening the sac.

Mr. Freke was a man not easily to be dissuaded from what he
had a mind to do; and having got the whim into his head, was
determined to make the experiment on this, which he thought a
fair case for the purpose. Accordingly (with his probe-scissors)
he divided the tendinous opening in the abdominal muscle; and
then again tried to reduce the gut, but to no purpose; for no-
thing would go up. At last, though with much reluctance, he
was obliged to lay open the containing membrane. He had no
sooner done this, than a large quantity of blood, partly fluid, and
partly grumous, burst forth, and the whole tumor subsided; leaving

A TREATISE ON THE HYDROCELE. 105

the process perfectly free; ami containing neither intestine nor
omentum.

The parts were now washed clean, and diligent search made
for the breach whence this blood issued; but none could be found:
the man was dressed with lint and pulv. boli armen. (a method
of dressing, which Mr. Freke was fond of) and, in a proper space
of time, the man got well without any new haemorrhage.

In this case, some of the circumstances might be said to render
an intestinal hernia not improbable; and the want of stools might
have increased such probability: but then it should have been con-
sidered, that although this be one symptom of the strangulated
intestine, yet it is not, by any means, an univocal, or infallible
one. A want of stools may happen from other causes, even in a
person who has a rupture, but cannot singly be a reason for the
operation immediately; which ought to be indicated and authorised
by other concomitant symptoms and appearances. A costive ha-
bit may attend a person who has an intestinal hernia, when the
gut labours under no stricture, and does its office perfectly well
in the scrotum;. but such patient will not have the symptoms of
an incarcerated intestine; nor indeed had this man. His not hav-
ing been at stool two days before, was an accidental circumstance;
which might or might not have been occasioued by the descent of
a piece of the intestinal canal: the truth of which should have
been proved by the use of a clyster and a purge, before an opera-
tion had been performed.

CASE XXXF.

A young fellow, straining to get rid of a hard stool, felt a sud*
den pain in his left groin; and, upon examination, found a swell-
ing, extending from thence into the scrotum. He took it for a
rupture, and immediately applied to an advertising operator; who,
after several unsuccessful attempts to reduce it, put a truss on him;
and told him that the tumor would gradually shrink to nothing.
The truss he wore for some days, when, finding both his pain and
swelling increase, he applied to a surgeon in his own neighbour-
hood; with whom I saw him.

vou if. o

A TREATISE ON THE HYDROCELE.

The tumor was large, and had somewhat the feel of an omen-
tal hernia; the abdominal aperture seemed to be dilated by it; the
testicle was tolerably distinct below; his pain in an erect posture
was considerable, but in a supine one, very little: he had neither
heat, nor quickness of pulse, nor hiccough, nor vomiting; and had
been thrice at slool that day.

As there was no reason for supposing any degree of stricture
on the intestinal canal, I advised the keeping him in bed, bleed-
ing him freely, and trying what a proper poultice would do.

This method was tried for several days, but without any bene-
fit: on the contrary, the pain increased, as well as the tumor; and
a fluctuation within became palpable.

This fluid I thought possibly might be collected in the sac of
an omental hernia (a case which I had more than once seen); and
as there was plainly enough in quantity to render a puncture per-
fectly safe, we made one with a lancet, and let out some ounces of
clear blood.

When the swelling was thereby lessened, we felt the spermatic
vessels, but could discern them very indistinctly; and the process
seemed much loaded and enlarged.

Next day the man was perfectly well in health; but the scro-
tum looked swelled, and black, as if it had been much bruised:
he had also bled from the puncture, which was not closed, and
discharged blood freely, upon any pressure being made above.

Though we were in some doubt concerning the true nature of
the case; yet it was clear, that if the haemorrhage continued, the
part must be laid open.

For three or four days it continued, notwithstanding all our
endeavours; and at last it was so considerable, as to indicate the
operation immediately.

A knife was introduced into the orifice made by the lancet, and
an incision of some length made; but no sacculus, no particular
cavity found; nothing like a hernial sac, or tunica vaginalis testis:
in short, nothing but cellular membrane; which satisfied us that
the blood must come from the spermatic chord.

As the bleeding still continued, and was derived from a part
above our incision, we continued it quite up to the groin, and
found that all the cellular membrane of the process was loaded

A TREATISE ON THE HYDROCELE. 107

with extravasated blood; and that it came from a considerable
breach now in view. We dressed it with lint, pressed out from a
styptic, and intended to have permitted that dressing to have re-
mained on for a day or two: but we were soon sent for on account
of an alarming return of the haemorrhage; which had been so
considerable as to produce a swoon.

Castration appeared to us to be the only remedy; and it was
immediately performed.

CASE XXXII.

A middle-aged man came to St. Bartholomew's hospital, and
desired me to look at a swelling in his groin and upper part of the
scrotum on the right side; which, he said, came suddenly, by
lifting a heavy weight. From the groin quite down to the testicle
the spermatic process was enlarged; he had no symptoms of a
hernia; and the testis was much too distinct and free for a hydro-
cele.

While I was examining it, I perceived some blood to drop from
the lower part of the swelling; and, upon inquiring the reason, he
told me that a puncture had been made in it a day or two -before,
upon a supposition that the swelling was from water; that it had at
intervals bled ever since; but that since it had last stopped, the
tumor was increased. From these circumstances, I concluded
the swelling to be caused by blood, shed into the tunica communis,
from a branch of a varicose spermatic vein.

He submitted to have it laid open? no particular breach was
discovered, though the whole membrane was much loaded: the
wound was dressed with lint pressed out from spirit, vin. These
dressings were suffered to remain on, until they were separated by
a beginning suppuration: and by keeping quiet, and being properly
taken care of, the man got well, without any return of haemor-
rhage.

108 A TREATISE ON THE HYDROCELE.

CASE XXXIII.

A poor man was brought to my house, by a gentleman of the
profession, for my own opinion concerning a tumor of the scro-
tum.

The swelling was large; of a globular kind of form; painful, not
only in general from its weight, but often even when suspended,
or when th£ patient was in bed. It palpably contained a fluid;
but the fluctuation of that fluid was not (to my fingers) like the
fluctuation of water. In all the posterior part of the tumor, an
enlarged, and somewhat hardened testicle might plainly be dis-
tinguished; and the general weight of the whole far exceeded that
of any hydrocele I had ever met with of equal size. That it was
not a mere simple hydrocele I was very clear: but, whether it was
a collection of fluid in the tunica vaginalis of a diseased testicle,
(what is in general called a hydro-sarcocele,) or what other morbid
or altered state of parts it might be owing to, I would not pretend
to say. A puncture was made in it with a small trocar; and
about four ounces of dark-coloured blood, not so fluid as blood
generally is while circulating in its proper vessels, was drawn off;
a bit of plaster and lint was applied to the orifice, and the man went
about his business.

In two days the same surgeon brought the man to me again.
The puncture was healed; but the tumor was as large as when I
had seen it two days before, and palpably contained the same
kind of fluid. What that was we" knew: and the consideration
was, what was the prop<arest method of giving the man relief.
Had he been in good health, I believe I should have advised lay-
ing the tumor open; at least so far as to have obtained a more
precise knowledge of its nature; but the patient's age and general
health were such as would by no means make an operation of that
sort an eligible thing. He was near to sixty; asthmatic; had drank
freely, and had a yellow countenance, and swelled legs in conse-
quence of it. I advised him to come into the hospital, and try
whether, by proper care, his habit might not be mended. Soon
after his admission, I had a mind to see whether the contents of

A TREATISE ON THE HYDROCELE. 109

the tumor were really the same as before, and made a puncture
in it again with the trocar; the discharge was again blood; and it
was two days from this operation, before a bloody discharge from
the orifice ceased.

A continuance of dram-drinking brought on a general anasarca,
and an extravasation of water in the abdomen; and when he had
been in the hospital about two months, he died.

I would not omit the opportunity of examining his scrotal dis-
order; and found, that the trocar had, at each operation, pierced
the tunica albuginea, that the bloody extravasation was within that
coat; that the tunica vaginalis was almost universally, though
slightly, adherent to the surface of the albuginea; that the vascu-
lar compages of the whole testicle was much enlarged, and at
the same time so loosened, that a part seemed to have been d is-
solved into the fluid which produced the fluctuation, which fluid
was mere blood; and that the epididymus was hardened, and very
considerably enlarged.

I have since had an opportunity of seeing a patient labouring
under the same complaint; whose testicle was rather hastily, and
inadvertently, laid open; that is, divided. The immediate conse-
quence was a large and obstinate haemorrhage. Whether it was
produced by the division of the substance of the testicle, or by the
irritation of such applications as were made use of for stopping
the bleeding, I will not pretend to say: but when I saw him, he
had a rigid neck; and was what is commonly called jaw-locked.
Castration, from the state in which his testicle was when I saw it,
must have been the only remedy for his local complaint; but his
spasmodic attack rendered that improper, and every thing else
fruitless.

I have also (from a very ingenious practitioner of my acquaint-
ance) received an account of a similar case, in which the testicle
was divided, and the haemorrhage (from the patient's obstinate
refusal to submit to the operation of castration) proved at last
fatal

110 A TREATISE ON THE HYDROCELE.

SECT. X.

To the different kinds of hydrocele, which have already been
mentioned, some of the modern French writers have added
another, viz. that which is formed by a collection of fluid in the
sac of a true hernia.

The title of this clearly describes its true nature; and therefore
I shall only inform the reader of what has fallen within my own
knowledge relative to this disease.

CASE XXXIV.

A young fellow, about twenty-five years old, applied to me on
account of a swelling in his scrotum. It was large, of an irregular
figure, not very tense, perfectly indolent, and accompanied with a
remarkable fulness of the spermatic process. '

The account which he gave of himself was, that he had had a
rupture as long as he could remember; that he had, on that ac-
count, worn a steel truss for many years; that, upon taking his
truss oft*, his rupture always came down immediately, and was
very easily returned up again; that it had never occasioned any
obstruction in his stools, nor given him any pain; that, about a
year ago, he had been persuaded to leave his truss off, and to sub-
stitute in its place, a bandage made of dimity, without any iron in
it, but which had been buckled on very tight; that, when he had
worn this bandage about six months, he found that his rupture
was down, and that he could not get it up again; that, upon this,
he had applied to the person of whom he bought the bandage;
who, after he had ineffectually tried to reduce the rupture, sold
him another bandage, and buckling it on still tighter than the
first, assured him, that it would never do hjm any harm; that,
from the time of putting on this second, his scrotum had gradually
become larger, with considerable pain and uneasiness.

From the feel of all the lower part, I made no doubt that the
tumor contained a considerable quantity of fluid; and had there

A TREATISE ON THE HYDROCELE'. Ill

been no other circumstance to influence my judgment, I should
have supp.osed the disease to have been a hydrocele of the tunica
vaginalis testis; but the very distinct and particular account which
the man gave of himself, and the feel and the appearance of the
spermatic process, made me hesitate.

Whatever might be the true nature of the case, a fluid there
certainly was; and that in quantity sufficient to render the dis-
charge of it both safe and warrantable. I made a puncture in the
middle and anterior part, and let out above a pint of brown se-
rum. This discharge removed all the swelling from below; but
made little or no alteration, either in the look or the feel of the
upper part of the process. I endeavoured to reduce it; but found
it impracticable, and desisted; advising the man to let it alone,
to wear no bandage of any kind; and if at any future time it be-
came troublesome to him, I desired that I might see it.

In about a year's time, he came to me again, with his scrotum
as big as before, and palpably containing a fluid.

As I had felt the testicle very plainly after the first operation,
and as I did not believe the tumor in the process to be formed by
the intestine, I advised him to have the whole laid open. He sub-
mitted, and I took him into the hospital for that purpose. I made
an incision, from the middle and anterior part of the scrotum,
quite up to the groin, and found in the lower part of the bag, which
contained the fluid, the testicle covered only by its proper coat, or
tunica albuginea; and in the upper part, or neck of the same bag,
a considerable portion of omentum. The upper part of this por-
tion of caul was hardened in its texture, and so perfectly adherent
to every point of the neck of the sac, as to prohibit the return of
even a fluid from thence into the belly: but the lower part was in
its natural stale, loose, soft, and capable of being expanded. All
the lower or loose part I cut off, without making a ligature, or
being troubled with any haemorrhage; the upper part I left as I
found it; filled the wound lightly with dry lint, and treated the
case as I should have done vhatof the .radical cure for an hydro-
cele. In about seven weeks the man got well, and has ever
since remained so.

This man's rupture was of the congenial kind; and therefore
the sac of the hernia, and that of the hydrocele, were the same, viz.
the tunica vaginalis testis.

1 12 A TREATISE ON THE HYDROCELE.

CASE XXXV.

While the first edition of this book was in the press, Mr. Sprat
desired fne to visit a patient with him, who had some pressing
symptoms of a strangulated rupture.

The patient was a healthy young man, about twenty-lwo years
old, and he gave the following account of himself.

That, as long as he could remember, he had been subject to a
rupture, which never came lower than his groin, was always easily
put up, and had never given him any trouble; that he had, when
a child, worn a truss, but, either from its being ill -made, or from
his not knowing how to put it on, it had never answered the pur-
pose, and that he had for some years disused it; that, for a month
or two past, his rupture had been constantly down; and that,
within that space of time, he had never been able to return it, though
he had often tried; that still, as it gave him no pain, nor produced
any other inconvenience than the mere swelling of the scrotum, he
had taken no notice of it, nor applied to any body for assistance
until within the last three days; since which, he had been affected
with great pain in his belly, a stoppage of stools, and a vomiting.

The lower part of the scrotum was much enlarged, contained a
considerable quantity of fluid, and bore very much the appearance
of a hydrocele; but the upper part, or spermatic process, was hard
and painful, and seemed to be girt light by the tendon of the
abdominal muscle. This, added to an extreme tightness of his
belly, want of stool for three days past, anxiety, restlessness,
vomiting, and beginning hiccough, determined me to propose the
operation immediately.

The lad consented, and I made an incision from the upper part
of the tumor, just above the abdominal opening, quite down to the
bottom of the scrotum.

Having carefully divided the cutis and common membrane, I
came to what appeared to be a hernial sac: this I opened, and
thereby let out about half a pint of clear limpid water; upon the
discharge of which the whole tumor of the scrotum subsided; and
my assistants were convinced, that I had mistaken a hydrocele for

A TREATISE ON THE HYDROCELE. 1 13

A hernia. But, although the whole of the swelling of the scrotum
was entirely dissipated by the discharge, yet the tumor and hard-
ness about the abdominal opening was unaltered, and the patient's
pain the same. With a probe-pointed knife I laid open the whole
sac, whence the water had proceeded, quite down to its bottom;
and found the naked testicle within it: this gave the disease still
more the appearance of a hydrocele, and I began to think that it was
so; but, upon passing my finger up to examine the state of the abdo-
minal tendon, I found a small portion of intestine engaged in it,
and bound extremely tight. I lengthened the incision, so as to
have a fair view of it, and thereby we all became thoroughly
satisfied of the true nature of the case. The piece of intestine
was small, a good deal darkened in colour, and bound so tightly by
the tendon, that it was with great difficulty that I could introduce
my finger for the conveyance of the knife. When I had made a
sufficient dilatation, I endeavoured to return the gut; but could
not execute it, although there was no obstruction from the tendon.
I drew out some inches of it, thinking that I might thereby be ena-
bled to make the return more easily: that which I drew out, I
replaced with the utmost ease; but could not disengage the small
portion which made the original disease. At last, passing my finger
round in the dilated opening, I found that the intestine adhered to
the lower border of it, by a small membranous filament; upon the
division of which the gut slipped in immediately.

The young man had stools very soon; and, by proper care, very
soon got well.

This also was a congenial hernia; the sac which contained the
intestine, the fluid, and the testicle, being the tunica vaginalis: but
had I been contented with merely dividing the tunic, and had not
proceeded in the examination and division of the abdominal tendon,
the lad would have been destroyed by the stricture.

vol. it.

114 A TREATISE ON TUE HYDROCELE-

SECT. XI.

The rest of the false hernias (as they are railed) are the pneu-
matocele, the varicocele, the cirsocele, and the sarcocele; to which,
some have added the hydro-sarcocele.

The first of these is (as I have already said) a mistake: there
is no hernia produced by mere wind. The two diseases, which,
in new-born children and infants, are taken for, and called wind-
ruptures, are, a tumor produced by a small quantity of fluid
remaining in the lower part of the tunica vaginalis, after its com-
munication above with the cavity of the belly is closed; and a true
(but small) intestinal hernia.

The varicocele is a dilatation of the blood-vessels of the scrotum.
These are of different size, in different people; and, like the vessels
in other parts of the body, are liable to become varicose; but are
seldom so much enlarged as to be troublesome, unless such enlarge-
ment is the consequence of a disease, either of the testicle, or of
the spermatic chord. When this is the case, the original disease
is what engages our attention, and not this simple effect of it; and
therefore, considered abstractedly, the varicocele is a disease of no
importance.

The cirsocele is a varicose distention and enlargement of the
spermatic vein; and, whether considered on account of the pain
which it sometimes occasions, or on account of a wasting of the
testicle, which now and then follows it, may truly be called a dis-
ease. It is frequently mistaken for a descent of a small portion
of omentum. The uneasiness which it occasions is a dull kind of
pain in the back, generally relieved by suspension of the scrotum,
It has been supposed to resemble a collection of earth-worms; but
whoever has an idea of a varicose vessel, will not stand in need of
an illustration by comparison. It is most frequently confined to
that part of the spermatic process which is below the opening in
the abdominal tendon; and the vessels generally become rather
larger, as they approach nearer to the testis. In books are to be
found prescriptions for lessening the distended veins; but I cannot

A TREATISE ON THE HYDROCELE. 115

say that I ever saw any good effect from external applications of
any kind.

In general, the testicle is perfectly unconcerned in and effected
by this disease; but sometimes it happens, that it makes its appear-
ance very suddenly, and with acute pain, requiring rest and ease;
and sometimes, after such symptoms have been removed, I have
seen the testicle so wasted, as hardly to be discernible.

CASE XXXVI.

A young fellow, on a journey, found himself one evening more
than ordinarily tired; and, as soon as he got to bed, was seized
with a violent pain in his back, which (to use his own words)
shot down into his stone.

The pain was so great, as to oblige him to send for somebody
immediately, who bled him freely: this produced no relief, nor
was the pain yet attended with any tumor of the scrotum, or tes-
ticle; or by any appearance whatever of the parts affected. The
pain continued, without remission, all the next day: he was again
let blood, had a clyster, and a gentle purge. On the third day,
toward evening, the pain totally left him, and a fulness appeared
in the groin, tending down toward the testicle: this made him so
uneasy, that, finding the apothecary, who had the care of him,
did not seem clearly to know what it was, he got into a post-chaise,
and came home to London.

His journey brought on a return of pain: but by losing some
more blood, keeping in bed, applying an emollient poultice to the
groin, and suspending the parts in a bag-truss, he became easy,
and all the tumefaction dispersed; except a small fulness of the
spermatic chord, occasioned by the varicose state of its vessels.
But the testicle was so diminished, as to be hardly perceptible;
and remains so, to the time of my writing this.

CASE XXXVII.

An ostler, at an inn in Smithfield, was, by the fall of a horse,
thrown over his head, and his groin struck against the pummel of

116 A TREATISE ON THE HYDROCELE.

the saddle. I' gave him exquisite pain; and he was brought im-
mediately to the hospital, upon a supposition that he had burst
himself.

Upon examination, no swelling appeared, either of the testicle
or of the spermatic chord; but the pain (which he said was ex-
quisite) was confined to that part of the latter, which is between
the testicle and the groin.

He was largely blooded, had a clyster, and a purge: his pain
continued 'wo days; and, when it left him, the spermatic vessels
became greatly varicose. No application, which was made use
of on this account, proved at all beneficial; that is, rendered the
distended vessels at all less; and, when he left the hospital, he
was perfectly free from pain: but his testicle, on that side, was
scarce discernible.

I once saw the same effect, from the injudicious application of
a truss, on a true circocele: the vessels, by means of the pressure,
became enlarged to a prodigious size, but the testicle shrunk to
almost nothing.

CASE XXXVIII.

A young gentleman about twenty-five years old, after having
heated himself much with exercise, went too soon into a river to
bathe. In the middle of the ensuing night, he was seized with a
coldness and shivering; which were followed with great heat and
thirst, and a slight sweat. He sent for a surgeon, who bled him
and gave him a clyster, bid him keep in bed, and drink plentiful-
ly. Next day, he gave him a laxative medicine, and some febri-
fuge draughts.

For three days, his fever was unremitting; but on the fourth he
became cooler, and was seized with a most acute pain in his loins;
for which he was again bled and purged. On the fifth day, his
back became easy; but both testicles, though very little swollen,
were so tender, as hardly to admit the touch; and, in a very few
hours, the spermatic vessels were so distended, as to make an ap-
parent tumor. By means of fomentation, poultice, and rest, all
tweasiness was removed in about a fortnight; but, at the end of

A TREATISE ON THE HYDROCELE. 1 I*

that time, both patient and surgeon were excessively astonished,
at not being able to fiud the testicles. The latter came to London
immediately, and desired me to examine him, after having given
me the preceding account.

The spermatic vessels were full, and varicose; the vasa differen-
tia too large, and rather too hard; as were also the epididymes: but
there was not, on either side, the least appearance of a natural
testicle. A flattened, compressed kind of membranous substance
(which, I suppose, was the tunica albuginea) seemed to hang from
each epididymis; but there was not any trace or vestige of the glan-
dular or vascular parts of either testis.

This is the only time I ever saw this complaint on both sides in
the same subject.

SECT. XII.

THE SARCOCELE, OR DISEASED TESTICLE.

This is a disease of the body of tne testicle; and, as the term
implies, consists, in general, in such an alteration, made in the
structure of it, as produces a resemblance to a hard, fleshy sub-
stance, instead of that fine, soft, vascular texture, of which it is h\
a natural and healthy state composed.

The ancient writers have made a great number of distinctions
of the different kinds of this disease according to its different ap-
pearances, and according to the mildness or malignity of the
symptoms, with which it may chance to be attended. Thus, the
sarcocele, the hydro-sarcocele, the scirrhus, the cancer, the caro
adnata ad testem, and the caro adnata ad vasa, which arc really
little more than descriptions of different states and circumstances
of the same disease, are reckoned as so many different complaints,
requiring a variety of treatment, and deriving their origin from a
variety of different humours.'

e " Humores crassi sunt duo, pituita et melancholia, e quibus turn scirrht
" in aliis partibus, turn indurationes earns: in testiculis oriuntur. Tumor hie

US A TREATISE ON THE HYDROCELE.

Every species of sarcocele consists primarily in an enlargement,
induration, and obstruction of the vascular .part of the testicle;
but this alteration is, in different people, attended with such a va-
riety of circumstances, as to produce several different appearances,
and to occasion the many distinctions which have been made.

If the body of the testicle, though enlarged and indurated to
some degree, be perfectly equal in its surface, void of pain, has
no appearance of fluid in its tunica vaginalis, and produces very
little uneasiness, except what is occasioned by its mere weight, it
is usually called a simple sarcocele, or an indolent scirrhus. If,
at the same time that the testis is enlarged and hardened, there be a
palpable accumulation of fluid in the vaginal coat, the disease has
by many been named a hydro-sarcocele. If the lower part of the
spermatic vessels and the epididymis were enlarged, hard, and
knotty, they supposed it to be a fungous or morbid acretion, and
called it the caro adnata ad vasa. If the testicle itself was unequal
in its surface, but at the same time not painful, they distinguished
it by the title of caro adnata ad testem. If it was tolerably equal,
not very painful, nor frequently so, but at the same time hard and
large, they gave it the appellation of an occult or benign cancer.
If it was ulcerated, subject to frequent acute pain, to haemorrhage,
&c. it was known by that of a malignant or confirmed cancer.
These different appearances, though distinguished by different ti-
tles, are really no more than so many stages (as it were) of the
same kind of disease, and depend a great deal on several acci-
dental circumstances; such as age, habit, manner of living, &c.
It is true, that many people pass several years with this disease,
under its most favourable appearances, and without encountering
any of its worst; but, on the other hand, there are many, who, in
a very short space of time, run through all its stages. They who
are most conversant with it, know how very convertible its mild-
est symptoms are into its most dreadful ones; and how very short
a space of time often intervenes between the one and the other.

" est durus, tacttii renitens, indolens, et si exquisitus sit scirrhus, sensu
" caret. Si a melancholia oriatur, color sublividus ; si a pituita, colorem
" cutis non mutat ; si a melancholia superassata, dolor punctorius, et inequa-
*' lis tumor; hie durus, ibi mollis."

Fab. ab Avupesdejtte.

A TREATISE ON THE HYDROCELE. 119

There is hardly any disease, affecting the human body, which
is subject to more variety than this is, both with regard to its first
manner of appearance, and the changes which it may undergo.

Sometimes the first appearance is a mere simple enlargement
and induration of the body of the testicle; void of pain, without
inequality of surface, and producing no uneasiness nor inconveni-
ence, except what is occasioned by its mere weight. And some
few people are so fortunate to have it remain in this state for a
very considerable length of time, without visible or material al-
teration. On the other hand, it sometimes happens, that very
soon after its appearance in this mild manner, it suddenly be-
comes unequal and knotty, and is attended with very acute pains,
darting up to the loins and back; but still remaining entire, that is,
not bursting through the integuments. Sometimes the fury of the
disease brooks no restraint; but making its way through all the
membranes which envelope the testicle, it either produces a large,
foul stinking, phagedenic ulcer with hard edges; or it thrusts forth
a painful gleeling fungus, subject to frequent haemorrhage.

Sometimes (as I have already observed) an accumulation of
water is made in the tunica vaginalis, producing that mixed ap-
pearance, called the hydro-sarcocelc.

Sometimes there is no fluid at all in the cavity of the tunica va-
ginalis; but the body of the testicle itself is formed into cells, con-
taining either a turbid kind of water, a bloody sanies, or a puru-
lent, fetid matter.

Sometimes the disorder seems to be merely local, that is, confin-
ed to the testicle, not proceeding from a tainted habit; nor accom-
panied with diseased viscera; the patient having all the general
appearances and circumstances of health, and deriving his local
mischief from an external injury. At other times, a pallid, leaden
countenance, indigestion, frequent nausea, colic pains, sudden
purgings, &c. sufficiently indicate a vitiated habit, and diseased
viscera; which diseased viscera may also sometimes be discovered
and felt.

The progress also which it makes from the testis upward,
toward the process, is very uncertain; the disease occupying the
testicle only, without affecting the spermatic process, in some

120 A TREATISE ON THE HYDROCELE.

subjects, for a great length of time; while in others, it totally spoils
the testicle very soon, and almost as soon seizes on the spermatic
chord.'

These, and some other circumstances to be mentioned hereafter,
are materially necessary to be observed; as they characterise the
disease, point out its particular nature and disposition, and serve
as marks whereon to found our judgment and prognostic of the
most probable event, as well as the most proper method of treat-
ment. Various have been the causes to which theoretic and
whimsical people have assigned this disease; but as a recital of
conjectures can convey no instruction or useful information, I shall
pass them over; and only take notice, that among the great num-
ber which have been mentioned, there are two, which, though
equally groundless with the rest, have yet obtained a degree of
credit that may mislead: these two are the hernia humoralis, and
the hydrocele of the vaginal tunic.

The hernia humoralis is a defluction of the inflammatory kind,
proceeding most frequently from an irritation in that part of the
urethra, where the vasa deferentia, or vesiculae, seminales termi-
nate. It is attended with pain and heat, and most frequently
fever. During the first, or inflamed state of the disease, the whole
compages of the testicle is enlarged; but when by rest, evacuation,
and proper applications, that inflammation is calmed, there seldom
or never remains, either fulness, hardness, or any other mark of
disease in the glandular part of the testis. The epididymis
indeed seldom escapes so well: that often continues enlarged and
indurated for a considerable space of time, but without producing
either pain or inconvenience; and without occasioning any altera-
tion in the figure or structure of what is called the body of the
testicle: whereas the true sarcocele, or hernia carnosa, most com-

{ This is the common language, and therefore I use it; but I would not be
understood to mean that the progress of the disease is always and invariably-
upward, from the testis into the process. I have seen the spermatic process
truly cancerous, when the testicle has been free from disease; and am well
satisfied, from experience, that a diseased state of the vessels within the ab-
domen, or of the parts in connexion with those vessels, may produce amor-
bid state of the process, proceeding downwards from thence; but the other
is by much the most frequent.

,_ A TREATISE ON THE HYDROCELE. 121

nionlvc begins by an indolent induration of that part of the testis,
and affects the epididymis secondarily; or after it has already
spoiled the vascular part of the gland.

I would not be understood to mean, that a sarcocele never fol-
lows a hernia humoralis; there is no reason in nature why it should
not: a hernia humoralis docs not, nor can prevent the testicle, in
any future time, from becoming scirrhous; I only say, that it does
not, at any time, necessarily cause or produce it. So also with
regard to the epididymis; I do not mean to say, that it never is the
primary and original seat of a scirrhus; I know that it is, and
and shall produce some instances of it. Neither do I intend to say.
that a scirrhus never attacks an epididymis, which has been pre-
viously hardened by a hernia humoralis: there can be no reason
why it should not; I only mean to signify, that it is my opinion,
that the induration caused by a venereal hernia humoralis does
not, at any time, necessarily produce a scirrhus. A scirrhus indeed
may fall on that part, after it has been so diseased, but it would
as certainly have attacked it, if there had been no preceding affec-
tion of it.

There is also a venereal affection of the testicle, independent
©fa gonorrhoea, or of any disease of the urethra.

This is seldom an early symptom; and I do not remember ever
to have seen an instance in which it was not either immediately
preceded, or accompanied, by some other appearance plainly
venereal. It has neither the inequality, nor darting pains of the
scirrhus, and always gives way to a mercurial process, properly con-
ducted.

A quantity of water is frequently collected in the vaginal coat
of a truly scirrhus testis. This has given rise to the supposition,
that the testicle often becomes diseased, from its being surrounded
by, or swimming in, the same fluid — a supposition entirely ground-
less.

That scirrhous and cancerous testes very frequently are found
to have a quantity of fluid accumulated in the tunica vaginalis of
them, is beyond all doubt; but that such testicles become diseased.

8 I say most commonly, because it is neither necessarily, nor always
VOL. II . 9

J 22 A TREATISE ON THE HYDROCELE. f

in consequence of being surrounded by such fluid, or, in other
words, that a simple hydrocele may produce a scirrhous testicle,
is by no means true.

The simple hydrocele is (as I have already at large observed) a
collection of water in (he tunica vaginalis: this fluio, in a
natural and healthy state of the parts, is small in quantity,
and, by being constantly absorbed, does not distend the ca-
vity of the tunic, but only serves to keep that membrane from
contracting any unnatural cohesion with the tunica albuginea.
The regular absorption of this thud being by some means prevent-
ed, the quantity soon becomes considerable, and, distending its
containing bag, constitutes the disease called a hydrocele; but
makes no morbid alteration in the structure of the testicle. 11

When the testicle becomes enlarged in size, hardened in texture,
craggy and unequal in its surface, painful upon or after being
handled, attended with irregular pains shooting up the groin towards
the back, and this without any previous inflammation, disease, or
injury from external violence, it is said to be affected with a
scirrhus. This, as I have already remarked, is of different kinds
and degrees, and appears under different forms; but, although the
appearances which the disease makes are various, according to the
alteration produced by it in the testicle, yet every such morbid
alteration may obstruct or prevent the regular absorption of the
fluid deposited in the vaginal tunic, and occasion a species of
hydrocele; that is, a tumour from water.

This is that kind of disease, which, by Fabritius ab Aqua-
pendeute, is called hydro-sarcocele; but which was so very unlike
to a simple hydrocele, that, whoever mistakes the one for the other,
will commit an error, which may prove very mischievous to his
patient, and very detrimental to himself.

In the true simple hydrocele, the testis, though somewhat loos-
ened in its texture, and a little enlarged, yet preserves very nearly
its natural form ; the collection is made without pain or uneasiness,
and very soon becomes sufficient to hide or conceal the testicle;
nor is the examination of such tumour attended with any pain; but

* That is, no such alteration as renders it painful, or incapable of executing
its office ; and, consequently, no such alteration as can ever require extir
pation, or any other chirurgical operation on the testicle itsd*"

A TEE ATI SE ON TIIF. .HYDROCELE. 123

the increased size, and hardened state of the scirrhous testis, renders
it discoverable, through a much larger quantity of fluid than will
totally conceal the former. When felt, it will be found to be
hard, and generally somewhat unequal, and not unfrcquently
attended with irregular shooting pains, especially after having
been examined.

In the simple hydrocele, the fluid distends the tunica vaginalis
so equally, that, although it does not surround the testicle, (nor
indeed can,) yet it seems so to do: whereas in the hydro-sarcocele,
though the anterior part of the tumor may, in some measure, bear
the appearance of a simple hydrocele, yet an examination of its
posterior part will always discover the true nature of the case:' to
which may be added, that, under the same apparent magnitude,
the latter will always be found to be considerably heavier than the
former.

In short, the name of this species of disease (hydro-sarcocele)
is undoubtedly a very proper one, and capable of conveying a very
just idea of its true nature, viz. an accumulation or collection of
water in the vaginal coat of a scirrhous or diseased testicle: but
the majority of writers have, by supposing the water to be the
cause, instead of the consequence of the diseased state of the
testis, committed a very material blunder, and endeavoured to
establish and authorise a very prejudicial and destructive method
of practice. For, by conceiving that the noxious quality of the fluid
produces a fungus or fleshy excrescence on the surface of the
testicle, they have supposed, that after having discharged the said
fluid from its containing bag, they could, cither by establishing a
suppuration, or by using escharotic medicines, waste or destroy

' This lias been very judiciously remarked by Mr Le Dran. Schenki us gives
an account of a beginning sarcocele, which was mistaken for an hydrocele;
upon which a radical cure was performed by castration. Upon dividing the
body of the testis, a quantity of thick fluid was discharged; a thing by no
means uncommon, but which was here mistaken for seme a The patient
died not long after the wound was healed; and the kidney on that side, and
the parts about it, made a very morbid appearance. This appearance
was by Schcnkius supposed to be owing to the hasty cure of the hydrocele;
feu' was indeed the effect of the same virus which had first spoiled the tesMcle,
Neither was the fluid in the body of it semen, bu sanies or matter; a cir-
cumstance most frequently met with in scirrhous testes.

124 A TREATISE ON THE HYDROCELE.

the said excrescence, and cbiain a radical cure of the whole dis-
ease. Now the scirrhosity of the testicle being the original disease,
£and the extrav salion a mere accident, such treatment can never
do any material good, and may often be the cause of very essential
evil.

Fabriiius ab Aquapendente has given a particular description
of this method, which he recommends, from having practised it
with success: his words are, " Modus singularis est quando hernia
" aquosa cum carnosa mista est; tunc enim primum incide, etfac
" foramen in parte scroti quae non sit declivis, neque in fundo
" scroti, sed circa medium; nee fac admodurn latum: et extracta
u aqua, turundam impone quam longissimam, medicamento, pus
" moventi infectam, ut resina terebinthinae, cum thure, ovi vitello,
" et butyro; cmplastrum emolliens, et pus movens applica, ut
" diachylon cum gummis, et axungia porci; genitum autem pus,
" non evacueter per forament, sed data opera intus servetur, ut
" contactu suo, carnem sensim pulrefaciat. Neque inovenda medi-
" camenta, nisi tota caro fuerit in pus conversa; id quod longo sit
iC tern pore. " k

Now, to pass over the absurdity of the doctrine of removing or
dissolving a fungous excrescence, by means of the putrefying
quality of matter, as well as the great disturbance which must be
the consequence of confining it within the tunica vaginalis, it is
very clear from these, and from every other circumstance attending
the disease in question, that the cases which Fabritius had success-
fully made his experiment upen, must have been mere simple
hydroceles, attended with a small degree of enlargement; but
without any diseased state of the testicle.

This is one method of procuring a radical cure of the said
disease — a method in use before Fabritius practised it, and still
in some measure employed — a method which, in some instances,
has always been successful; and which may, in general, be tried
on any simple hydrocele, in a young and healthy subject. The

»■ " Si carnosa, et aquosa sit hernia, ego talem adhibeo curam ; seco cutem,
" et incisionem facio exiguam, et i n loco potius altiorc, quam in fundo : inde
" turunda imposita cum digestivo et pus movente medicamento diutius
" procedo, neque unquam pus cxtraho, sed perpetuo bonam partem intus
•** xelinquo ; quod sensim carnem corrodit, et ita sanat."

V THEATISE O.N TUB IIYDROCT.LL. 125

cure (when it effects one) is not brought about by the destruction
of an excrescence from the testicle, or the dissolution of its sup-
posed induration; but merely by exciting such an inflammation, as
shall occasion an adhesion of the tunica vaginalis to the tunica
ulbuginea; by which means, the cavity of the former is oblite-
rated; tiie testicle remaining, as to size and consistence, just as it
was before such operation was performed. 1 But this, though
practicable, and sometimes successful in the hydrocele, is not to
be thought of in the diseased or scirrhous testicle. The operation,
as described by Aquapendente, consists of two points; first to let
out the water, and then to cause a plentiful suppuration. When
the testicle is really and primarily diseased, and the extravasation is a
consequence of such disease, the discharge of the water from the
cavity of the tunica Vaginalis, whether by puncture, or by incision,
can contribute nothing material toward a cure of the principal com-
plaint, and is therefore useless; but it may, in many cases, do
harm, by creating a disturbance in parts whose slate requires the
most perfect quietude; and is therefore wrong. When the disease
is a mere simple hydrocele, the palliative cure, as it is called, by

1 Another method of treating this disease, in use before Fabritius ab Aqua-
pendente, (as may be seen in Guido and others,) and much preferable, if used
in proper cases, is the method by seton.

This, as 1 have already observed, I have several times practised with
success, in those who would not submit to incision, or in whom it was by no
means proper.

Fabritius ab Aquapendente had a different, and that an erroneous, idea of
this disease : he conceived that there was a fungous kind of excrescence on
the testicle, aiid that this excrescence required erosion and destruction ;
this he aimed at accomplishing', by means of the matter collected within ; and
therefore his principle aim was to confine and increase it, by making- his
puncture, for the introduction of his tent, in the upper part of the tumor;
and by imbuing it, from time to time, medicamentis pus moventibus.

Had he been right in his idea, his practice would have been just ; but his
conception of the disease was erroneous, and bis practice absurd. The
rational intention should be, to excite such a degree of inflammation as may
produce an union between the tunica vaginalis and the albuginea. The forma-
tion of matter is a mere accidental consequence of this inflammation; and
the means used to procure the end (provided it be procured) cannot be too
gentle. The matter is of no real use, and therefore it is so far from being
necessary to confine it, that if the conjunction of the coats can bo obtained,
•without the formation of anv, it is so m.uch the better

126 A TREATISE ON THE HYDROCELE.

puncture, is right and necessary: it renders the life of the patient
easy; rids him, every now and, then, of a very troublesome burden;
is perfectly safe; may be performed and repeated occasionally, at
any time of the patient's life, or in almost any slate of the disease;
bui the introduction of tents or setons, or the endeavour by any
means to excite inflammation, or to establish suppuration within
the tunica vaginalis, requires (even in the simple hydrocele, where
the testicle is unaffected) some little consideration, and ought not
to be hastily or unadvisedly put in practice.

In some ages, habits, &c. the symptoms will rise very high, and
occasion both trouble and hazard; and if this be the the case, when
the testis is not at all diseased, and when there is no malignity,
cither in the local complaint, or in the habit of the patient, what
have we not to fear where there is both? where the parts are al-
ready spoiled by disease, and where irritation and inflammation
may (and do) excite the most fatiguing symptoms, and the most
direful consequences?

Besides the hydro-sarcocele, or lympid extravasation of fluid,
in the cavity of the vaginal coat, (and which must therefore always
be external to the testicle,) scirrhous and cancerous testes are lia-
ble to collections of fluid, within the substance of them, under the
tunica albuginea. m These are sometimes large, and in one cavi-
ty; sometimes small, and in several distinct ones. They are also
very different in nature, in different cases; sometimes serous,
sometimes sanious; sometimes purulent; sometimes bloody. These
are very apt to impose on the inadvertent and injudicious (espe-
cially if they be attended with some degree of inflammation in the
skin); and to induce an opinion of an abscess, or imposthuma-

'« Job a Meekren has made a very just and judicious remark on this sub-
ject. Fabritius ab Aquapendente had reckoned a collection of fluid, within
the tunica albuginea testis, among the kinds of hydrocele. This Meekren
does not allow ; but, having described the true hydrocele of the vaginal coat,
speaks of this collection within the albuginea, as it really is; that is, as a con-
sequence of the diseased state of the gland. His words are, " Hieronjmus
" Fabritius ab Aquapendente, Part I. de Operat. Chirurg. cap. 75 aquam in
" testibus congregari docet earn quae ex imo ventre eo defluit : at error est
'•' (meo judicio) magni anatomici. Spatio enim eo, quod est inter testiculum
" et tunicam, imo in scroto ipso, aqua ssepius colligitur : nunquam in testibus
n ipsis, nisi putrescent.'"

A TREATISE ON THE HYDROCELE. 127

tion, which may be relieved or cured by an opening; but caveat
operator. These collections will be found to bear a much srrjaller
proportion to the general size of the tumor, than they who are not
conversant with them are inclined to apprehend; the subsidence,
after the opening has been made, will also be much'smaller than
was expected; and instead of relief and ease, all the symptoms of
pain, swelling, inflammation, &c. will be increased and aggravat-
ed; and if the opening be considerable, it not infrequently happens
that an ill-natured fungus is thrust forth, which, by bleeding,
gleeting, and being horridly painful, disappoints the surgeon, and
renders the state of the patient much, more deplorable than it waa
before. Neither is this sensation, which is thought like the fluc-
tuation of a fluid within the testicle, to be at all times depended
upon as implying that there is any fluid at all there. The touch,
in this case, is subject to great deception; and I have seen a loosen-
ed texture of the whole vascular structure, or body of the testicle,
produce a sensation so like to the fluctuation of a fluid lying deep,
as has imposed on persons of good judgment and great caution.

Many of the most esteemed writers on this part of surgery, either
not being practitioners, or being afraid to differ from those who
have written before them, have lazily and servilely copied each
other, and have thereby fallen into an obscure jargon concerning
this disease, which neither themselves nor their readers have un-
derstood. They have talked of the scirrhous testicle, (he care
adnata ad testem, and the caro adnata ad spermatica vasa, as so
many different diseases, requiring different methods of treatment.

The melancholia, the atra bilis, and a certain inexplicable adust
state of humours, are said to be the causes of these different appear-
ances,- and the fleshy substance arising from, or adhering to, the
spermatic vessels, is said to be more benign, than either the fun-
<ius arising from the testicle, or the true scirrhus. For the first,
they have described an operation, which is coarse, cruel, painful, and
(notwithstanding all that they have said about it) unsuccessful; all
which they must have known, if they had practised it. I therefore
am much inclined to believe, that this is one of the many parts of
ancient surgery, which, having been devised by some one bold,
hardy operator, and by him described as practicable, has been re-
lated by many of his successors as practised. The second, the

128 A TREATISE ON THE HYDROCELE.

caro adnata ad tcstcm, they allow to be allended with more diffi
culty, as well as hazard, and seldom to be attempted with suc-
cess."

" "Ramex h:ec inter excresccntias annume rari potest, cum sit additamen
" turn ex toto praeter naturale ; nee illi insunt signa apostematis, sed tantum
" utcaro qua; circa scrotum aut epididytnem generari solet."

AnDUEAS a Crttce.

" Curatio ejus est, ut incidatur cutis testiculorum, et excorietuv usque atl

" superiora ; deinde extrahe didymum et testiculum, et libera eos ab omni

" parte ex illo carnositate."

Bruxus.

" Fit etiam hernia quandoque ex carnositate quadam prseter naturam nas-
" cente juxta testiculum ; et tunc pellicula incisa undique debet excoriari ,
" et discooperta carnositate ilia a corio exteriori usque, superius cauterio
"' abscindatur."

RolAKUUS.

" Cura ejus non potest fieri nisi cum manu pellem exteriorum scihdendo,
•' ; et carncm a testiculis scarnando, et incarna-auferendo."

Lanfraxc.

". Scinde pellum testiculi cum rasorio usque ad testiculum, et tunc carno-

" sitatcm, quam invenis, removeas et excarnes totalitur a testiculo."

Gul. f. Saeiceto.

" Notandum est in hac operationc num caro concreverit circa tunicas, an
" circa jpsos testis ; numque firmiter an minus firme adhereat partis sub-
" stantise. Incidendum esttotum scrotum usque ad carnem concretam, qux
" si quidem valenter haud sit afftxa, vel summis digitis, vel manubriolo scal-
" pentc, a teste vel tunicis, sensim sit auferenda."

FAB. AB AaUAPEXDENTE.

" Caro item sxpissime testiculis, aut eorum tunicis adnascitur, serosus
'• enim humor iste nonnunquam acris factus venas capillares, membranasque
" leviter erodit. Hinc pars ilia sanguinis que paulatim exudat, quaeque op-
'•' tima et laudibilis est, beneficio caloris innati, in carneam substantiam con-
C( crescit, &c. reliquum vero sanguinis quod serosum est, paulatim mem-
" branas totumque scrotum adco extendit, ut caro iSta quje testiculo adherit.
" digitis palpari non possit."

FABUITICS HlEDATfUS.

" Secandum est scrotum, et detegenda caro, et a teste deradenda vel a
" vasis, &.c."

Gab. FALEOnus.

The false reasoning, tlie want of anatomical knowledge, the cruelty and
inutility of the proposed operations, and the terrible consequences which
must follow from their being put in practice, are too glaring to need any com-
ment ; and such as must incline every reasonable man to hope, that these
authors (and a great multitude of others, who might be named) did in this"

A TREATISE ON THE HYDROCELE. 129

They who are under a necessity of forming their opinions
principally from books, and who have not frequent opportunities
of knowing from experience, how very little they are (in many
cases) to be depended upon, may be inclined to think that all
these distinctions really exist; and that these operations by fire
and sword, by knives and cauteries, so exactly described, must be
sometimes necessary; but having never seen the particular cases
requiring such treatment, have a very imperfect idea, either of
them, or of the operations; and are, to the last degree, alarmed and
intimidated, when any thing, which they think is like to it, oc-
curs to them in practice. To such, it may not be amiss to ex-
plain this matter, in as few words as I can; begging pardon of
the more intelligent reader for the digression.

In the short anatomical account which I have given of these
parts, 1 have taken no notice, that the spermatic vessels terminate
in the testicle; and that, after the semen has been secreted from

part of surgery as they have done in many others ; that is, copy each other

in the precepts relative to the cause and treatment of this disease, but did

not put their directions often into practice. The imperfect slate of anatomy,

in the time of the above cited writers, may be admitted as an excuse for

them ; but even very late ones have fallen into the same error.

" In the fungous excrescence upon the testis, when the same is not over- |

grown, you are to make way thereto ; which is then to be consumed by

cscharotics, or by the actual cautery."

Turner.

" Si quid vero carnis enatum a tcsticulo deprehenditur, quod gravitcr
" homincm affligat, nee discuti tamen per adhibita medicamenta convenien-
' tia queat, turn si testiculus integer adhuc est, atque illibatus, feliciter ut
" plurimum sanari noxa poterit, ipscque testiculus servari •, dummodo quic-
•' quid prater naturam super increvit, deoperto scrotu, qu am exactissime ab eo
" eolvatur, atque rescindatur."

"Quod si autem ipsum testiculum invaserit: vel exindi etiam propter
" nimios cruciatas, vel similes alias causas, indecore prominentes partes
" nequeant, necessarium utique erit, vel universum testiculum, vel quondam
" saltern ejus partem, modo jam proposito exscindere."

Hkister.

Te set aside the strange distinction between the "caro enata a testiculo,"
and that " qux ipsum testiculum invaserit," (a distinction taken from books
only,) I believe I may venture to say, that the professor never found, that
the operations which he describes and advises, were attended with success;
and I hope that he has not often seen them performed.
VOL. IT. R

J.'iO A TREATISE ON THE HYDROCELE.

the blood, it passes from that gland into a body which seems su-
peradded to, although it be really continuous with, it. This body
is therefore called the epididymis, and is so placed, with regard
to the testis, that a heedless or uninformed observer may suppose,
that the spermatic vessels terminate in it; especially if it be en-
larged bv disease. It lakes its rise from the testicle, by a num-
ber -of vessels, called from their office, vasa efferentia: these soon
become one tube, which, being convoluted and contorted in a
most wonderful manner, forms the greater part of the said body:
and at last, ceasing to be so convoluted, it ends in one firm canal,
called the vas deferens; by which the secreted semen is conveyed
from the testicle to the vesiculae seminales.

Whoever will attentively consider the epididymis in its natural
position, with regard to the testicle and the spermatic vessels,
will see, that if it be enlarged beyond its proper size, it will ex-
fend itself upward, in such a manner as to seem to be closely con-
nected with them, and to bear the resemblance of a diseased body,
springing from them.

This is the case called the caro adnata ad vasa spermatica ;
and is really and truly nothing more, than an enlargement of the
epididymis;* circumstance which occurs not infrequently, but
does not imply any malignity, either in the part or in the pa-
tient's habit; and can never require such a horrid operation as
our forefathers have directed us to perform upon it; nor indeed
any at all.

The epididymis is frequently enlarged, in venereal cases, either
separately, as in the remains of a hernia humoralis, or together
with the testicle, in that affection of it, which I have called the ve-
nereal sartocele; and sometimes from mere relaxation of its na-
tural texture, without any disease at all. But in none of these
can it require, or even admit, any manual operation of any kind.
Indeed, whoever will consider the epididymis, as it really is, as
the medium by and through which the semen is conveyed from
the testicle to the vas deferens, must immediately be sensible of
the glaring absurdity of removing any part of it.

The scirrhus and cancer do not very often begin in this part:
they most frequently make the first attack on the body of the testis;
and, though the epididymis is often cancerous, yet it most frequently

A TREATISE ON THE HYDROCELE. 13J

becomes so secondarily, or after the testicle is spoiled; so that
the removal of it, if practicable, could serve no good purpose, i!
would not remove the disease; for that has, before-hand, most
commonly taken possession of the testicle; -and the cutting off an\
part of a scirrhous or cancerous tumor of any kind, is what no
man, who has the least knowledge of what he is about, will ever
think of.

In short, these two cases, which, by the inattention and misre-
presentation of our ancestors, have created such perplexity in the
minds of their readers, are either a simple enlargement of the epi-
didymis, without any morbid alteration in its structure; or a dis-
eased (that is, a scirrhous) state of the same part; or else, a scir-
rhous or cancerous testicle, with inequality of surface. The fust
of these requires no manual operation of any kind; and the two
last will admit of none: the first is no disease at all; and the two
last are such diseases, that every attempt made on them, by knife
or caustic, (unless for total expiration,) must render them worse,
and more intractable.

The manner of treating a sarcocole, or hernia camosa, depends
entirely on the particular nature and state of each individual case.
In some, it will admit of palliation only; in others, the disease
may be eradicated by the extirpation of the part; so that, under the
article of method of cure, we have only to consider, and point out.
as clearly as the nature of the disease will permit, what states
and circumstances, both of it, and of the patient labouring under
it, forbid the operation, and what render it advisable.

On this head, great variety of opinions will be found among
writers; so great, that a man, who is under a necessity of forming
his judgment from them, will find himself under some difficulty
how to act; and so great, that I cannot help thinking it to be
clear, that the majority have not written from practice, but from
mere conjecture, or from the works of those who who have gone
before them.

Some have given it as their opinon, that while the testicle is
perfectly indolent, (let the alteration in its structure, form, or con-
sistence, be what it may,) it is better to suffer it to remain, than
to remove it. In support of this opinion, they say, that although
the disease has plainly taken possession of the part, yet, while it

132 A TREATISE ON THE HYDROCELE.

causes no pain, the constitution receives no damage from it; nor
is the health of the patient impaired by it; whereas, by removing
the testicle, the same virus may seize on some part of more con-
sequence to life. This 1 method of reasoning takes for granted two
things, which do not appear to be strictly or constantly true, viz.
that this disease is never perfectly local; and that a scirrhous
testicle, though free from pain, will not in time produce any evil
to the general habit of the patient. Others advise us to stay until
the tumor becomes painful, and manifestly increases in size, or ac-
quires a sensible inequality of service: that is, (in other words,)
until it begins to alter from a quiet state to a malign one: which
advice, as well as the preceding, supposes that the hazard of the
mere operation of castration is loo great to render it an advisable
thing, until the patient is pressed by bad symptoms; and that a
scirrhous testicle, which has been quiet and free from pain for
some time, may be as successfully extirpated after it has become
painful, and has acquired a malignant and threatening state, as at
any time before such alteration. The latter of these will hardly
be admitted (I believe) by those, who form their opinions from
experience; and with regard to the former, I can, with great
truth, affirm, that I never saw the mere operation of castration,
when performed in time, and on a proper subject, prove fatal.

Many people have I known, who have lived several years, their
whole lives, perfectly free from disease, after the removal of quiet,
indolent, scirrhous testicles; and several have I known, wjio, hav-
ing deferred the operation until they were urged by pain, increase
of size, and inequality of the tumor, have, from the sore becoming
cancerous, not been able to obtain a cure. That I have seen the
same thing happen, after the removal of a testicle, circumstanced
in the best manner, is beyond all doubt; but not near so frequent-
ly as in those cases in which the operation has been deferred un-
til the symptoms became alarming, and the disease had changed
its appearance, from a benign quiet one, to one that was malign
and painful. Indeed, were we capable of knowing with certain-
ty which those scirrhi were, that would remain quiet and inoffen-
sive through life, or for a great length of time, and which would
not, we should then be enabled to advise or dissuade the operation
upon much better (that is, much surer) grounds, than at present

A TREATISE ON THE HYDROCELE. 133

we are able to do. We have no such degree of knowledge; all
our judgment is formed upon the mere recollection of what has
happened to others in nearly similar circumstances; and experi-
ence, though the best genera! guide, is, in these cases, more falla-
cious than in many others.

A few people there certainly have been, who have been so
fortunate as to carry a scirrhous testicle through many years,
with little or no pain or trouble: but the number of those, in
whom time (and that frequently a short space), change of con-
stitution, external accidental injury, &c. do not make such an
alteration in this disease, as to render the operation less likely to
be successful than it would have been at first, and under more
favourable circumstances, is so small, that I think early castration
(that is, as soon as the disease is fairly formed and characterised)
may be recommended and practised by every honest and judicious
surgeon.

o Scirrhous and cancerous tumors are found in many parts of the body, as
well as in the testicle; and in all others, as well as in that, bear different
characters; that is, show a greater or less disposition to malignity ; remain-
ing' sometimes of small size, and easy for many years ; at others, increasing
fast, and so producing great pain, and all its bad consequences.

Of all the kinds of this disease, those which follow upon some external
violence (such as blow, bruise, &c.) are thought and said to be the least ;
therefore, great regard has always been paid to this distinction by writers,
and great hopes conceived from this circumstance by patients. I wish I could
$ay that such hopes were always as well founded as they are thought to be.
I mean, that experience most frequently verified them.

"When a scirrhus seizes a part that has previously sustained an injury from
without, such probable cause is undoubtedly a favourable circumstance ; but
it does not, by any means, necessarily follow from thence, that the constitu-
tion of such person is free from taint. It is a presumption, but not a proof;
and this presumption becomes more reasonable, if the diseased state of the
part follows such accidental injury soon, than if it appears at a great distance
of time.

No man will pretend to say, that such mischief has not been done by out-
ward violence, that cancerous disorders have not followed, in the parts so
injured, in persons, who, before such accident, never had any appearance of
such disorder; and who possibly might have lived many years, nay, their
whole life, without its appearing in such form and manner: but that, pre-
vious to such accident, there was no cancerous disposition or malignity in the
babit, is an inference which cannot be admitted.

What disorders of the joints do we see produced by very slight injuries

134 A TREATISE ON THE HYDROCELE.

Indeed, the circumstances of frequent pain, and the manifest
tendency to an increase of size, are by some people looked on as

done to them ? disorders which are clearly and plainly scorphulous, and
which would not have appeared at that time, or in that part, had it not been
for such accident ; but surely no nun will from thence conclude, that such
people have no scrophulous taint in their blood, or glands, previous to such
strain or bruise. How many internal part-, are there for this disease, as well
as some others, to make its attack upon ; but which, by being out of sight,
and not deemed objects of surgery, are not known; and pass either for other
diseases, or for the symptoms of other diseases r What tumors of the lum
hal glands and mesentery; what obstructions, in all parts of the contents
both of the abdomen and thorax, do we not find, upon examining the dead,
whose disorders were very little known or understood while they weic
living; but whose prevailing indisposition, whose natural dyscrasia, would
most probably have shewn itself in some more visible part, if such part had
accidentally suffered from external violence ?

All that we from experience know, and therefore all that we ought hones'.
ly to say on this occasion, is, that it lias vevy often happened, that where that
kind of disorder, which produces scirrhous or cancerous tumors, has been
brought into action by external injur) (whether it be in the breast, testicle, or
any other part, it matters not); or when such kind of disease lias seized such
part, no preceding violence having been ottered to it, and has therein occa-
sioned a fixed but indolent kind of swelling, which has either remained a long
time of one sixe and state ; or, if it has altered, has altered very slowly, and
given the patient but little uneasiness; if such tumor has been so situated
and circumstanced, that it could safely be extirpated or removed, that such
removal or extirpation has often cured the present evil; and that the patient
has remained free from any thing of like sort, during his or her life.

This is true, and therefore is and ever will be a sufficient reason for press-
ing such operation, when all other circumstances are favourable. That the
patient may keep well after it, is by no means improbable; that the scirrhus
wotdd remain, through life, indolent and inoffensive, is very improbable. But
whoever boldly asserts, that such extirpation will always and certainly cure
the disease, is very inexperienced, or is wilfully guilty of a deception, the two
distinguishing marks of a quack, who always promises, what lie either does
not know, or does not believe.

"When a scirrhus or cancer is favourably circumstanced, and so situated at
that it may be extirpated, such extirpation is indeed the only remedy : and
that method by which such extirpation can be most certainly and expedi-
tiously executed, is, beyond all doubt, the best.

The two in use are, the knife and the caustic. The former, in the hand e.-'
a surgeon who is an anatomist, has every advantage which can be desired or
supposed : it gives less pain, is more secure and more expeditious; but it im-
presses on the patient the apprehension of an operation, and the fear of an
hemorrhage. The use of caustic is infinitely more painful, not only in imme-
diate sensation, but in duration; it often requires repetition ; it is less man-

A TREATISE ON THE HYDROCELE. 135

auch marks of a malignant disposition, that they have been by them
reckoned as dissuasives from the operation.

ageable, less secure ; and ilie great length of time which sometimes the sepa-
ration of the mortified parts takes up, renders it very tedious. Bat it is at-
tended with two circumstances, which have greatly contributed to the support
of cancer quackery : one is, that it spares the patient the horror of an opera-
tion, which, though infinitely less painful than the effect of the caustic, is not
believed to be so ; the other is, that the ragged appearance, which the bottom
and sides of the parts m.tkc after having been removed by such application,
is so unlike to the smoothness of that which has been removed by incision,
that ignorant people are easily induced to believe, what the designing always
tell them, viz. that the medicine has taken their disease out by the roots ; and
that the ragged parts which they see, are such roots.

It is amazing what weight this single circumstance has with many, and
even with some sensible people; few of whom are persuaded to believe what
is as true as any proposition in Euclid, viz. that the caustic of equal strength,
applied on any glandular part of any person, will always produce exactly the
same effect and appearance, as, in this case, passes with them for the roots or
branches of the disease.

When nurses and quacks talk of the fibrous roots of a cancer, and of can-
cerous fermentations, they are excusable ; the one from their ignorance, the
other from the nature of their trade ; but when they who pretend to some
kind of medical knowledge use this kind of language, it is shameful.

If either the fears of the patient, or the particular circumstances of the part
to be removed, render the use of caustic preferable, or necessary, every prac-
titioner is well acquainted with those which are perfectly efficacious; but
every practitioner also knows, that good reasons for preferring the use of
them to the knife very seldom occur : it is in this as in the attempts toward a
radical cure for ruptures, and some other parts of surgery, we are censured
where we ought to be applauded, and blamed for those very things from
whence we ought to derive praise. We have laid aside certain methods and
processes, because we found them (upon experience) to be painful, hazard-
ous, and ineffectual; ami these very methods, destructive and infallible as they
arc, have given credit and honour to those who have had ignorance and in-
humanity enough to revive them.

We are not yet so happy as to be possessed of any medicine which will
cure a cancerous habit. When the constitution is thoroughly infected, nei-
ther our knives nor caustics will avail : they can only remove the local mis-
chief, but can have no effect on the general one in the constitution. Who-
ever says otherwise, says what is not true ; and whoever believes otherwise,
is imposed upon. When the habit is concerned, as it too frequently is, it
must be an internal remedy that proves a specific, whenever we are so hap-
py as to be blessed with the discovery. The supposition, that an escharctic
can, by destroying a particular part, eradicate the disease from the habit, is
(one would be inclined lo suppose) too gross an absurdity for the inns: cre-
dulous believer to swallow ; and yet it is believed, and trusted to every day.

136 A TREATISE ON THE HFDROCELE.

But these gentlemen carry their fears and apprehensions much
too far the other way. Pain and a quick increase of size are
certainly no favourable symptoms; they show a disposition to mis-
chief, but they are not such positive proofs of a cancerous habit,
as to render all hope of a cure, from the removal of the diseased
part, vain: there are many instances to the contrary; and though
no honest or judicious man will venture to promise success, even
in the most favourable of these cases, yet it is well known, that
those which have had very unpromising appearances, not only
from the state of the testicle, but from that of the spermatic
chord, have succeeded often enough, to make the chance of a
cure, by the operation, by no means a desperate one. The state
of a man left to his fate in these circumstances, that is, to the fury
and progress of the disease, is so truly miserable, that nothing
should be left unattempted, which carries with it any probability
of being serviceable; and a practitioner is vindicable, in pressing
what he has known to be successful; though, at the same time,
he ought to make a guarded kind of prognostic.

Upon the whole, I think it may justly be said, that the man
who has the misfortune to be afflicted with a truly scirrhous tes-
ticle, has very little chance (notwithstanding all that has been
said and written about specifics) to get rid of it by any means,
but by extirpation; and all the time the operation is deferred, he
carries about him a part not only useless and burlhensome, but
which is every day liable, from many circumstances (both exter-
nal and internal) to become worse, and more unfit for such ope-
ration.

While the testicle is small, and free from acute or frequent
pain, the vessels from which it is dependent are most frequently

Indeed, it sometimes happens, in the treatment of these cases, that either thcr
arrival of puberty, a favourable turn in a constitution, or the renewal of long-
obstructed evacuations, (especially the uterine ones,) shall restore the patient
to a better state of health, and prevent either the further progress of the dis-
order, or any new appearance of it in any other place. In this case, if the
extirpation was made by an external application, and not by an instrument,
6uch application is thought to have wrought the cure, and has all the credit
of doing what it really had no share in then, what it never can do, nor have
the appearance of doing again, but in the like accidental circumstances.

A TREATISE ON THE HYDROCELE. 137

soft, and free from disease; whereas, when the testis has been suf-
fered to attain a considerable size, the case is frequently otherwise;
the spermatic vessels are often large and varicose; and the cellular
membrane investing them sometimes becomes thick, and contracts
such connexions and adhesions, which, though they may not
amount to an absolute prohibition of the operation, do yet render
it tedious, troublesome, and more hazardous, than it would be in
other circumstances. Every addition to the original complaint
in the body of the gland is against the patient; and if any of these
are the consequence of not having removed it in time, it will fol-
low, that the sooner it is removed, the better. If we wait for what
some call indications of the necessity of operating, we shall often
stay until it will do no good. Many a one have I seen lose a very
probable chance of a cure by delay: but I do not remember ever
to have seen a testicle removed, by a man of judgment, which tes-
ticle did not, upon ' examination, fully vindicate the extirpation.
If we were possessed of any medicine, either external or internal,
which had been known now and then to have dissolved scirrhi, it
would always be right to recommend the trial of them previous to
an operation; and it would always be right to defer operating until
such trial had been made. But the truth is, we know no such
medicine. The credulous on the one hand, and the designing on
the other, have told us many strange stories of cures effected by
such applications and remedies; and I do most sincerely wish,
that what each of them have said was true; but repeated, faith-
ful experience has proved that it is not; and that they who have
placed their confidence in them, or laid out their money on them,
have been disappointed and cheated.

Some circumstances there are now and then attending this dis-
ease, which are out of our sight, and out of our knowledge, and
which will render all our pains abortive: such are tubercles, indu-
rations, and other diseased appearances in the cellular membrane
enveloping the spermatic vessels within the abdomen; scirrhus, vis-
cera, &c. If any of these can be known, they constitute a good rea-
son for not attempting the cure by the operation; but the mere possi-
bility that such may exist, is certainly no reason for abstaining from
it. The apparent evil, that is, the diseased testis, is certain; the other

VOL. II. s

138 A TREATISE ON THE HVDROCELE.

may or may not be the case. The one, if left to itself, is most
likely to destroy the patient in a most miserable and tedious man-
ner; and the other (the suspected mischief) may possibly not
exist.

But though the timely and proper removal of a scirrhous or
cancerous testicle does frequently secure to the patient life, health,
and ease, which, in such circumstances, are not attainable by any
other means; yet it must be Remarked, that the improper and un-
timely performance of the operation is not only not attended with
such happy and salutary event, but generally brings on high symp-
toms, and quick destruction. It therefore behoves every practi-
tioner to be perfectly well acquainted, not only with such circum-
stances as render castration practicable and advisable, but with
those which prohibit such attempt.

These are of two kinds, and relate either to the general habit
of the patient, and the disorders and indispositions of some of the
viscera, or to the state of the testicle and spermatic chord.

A pale, sallow complexion, in those w r ho used to look otherwise;
a wan countenance, and loss of appetite and flesh, without any
acute disorder; a fever of the hectic kind; and frequent pain in
the back and bowels, are, in those who are afflicted with a scir-
rhous testicle, 6uch circumstances as would induce a suspicion of
some latent mischief, and incline one to suppose that the same
kind of virus, which had apparently spoiled the testis, may also
have exerted its malign influence on some of the viscera: in which
case, success from the mere removal of the testicle is not to be
expected. They, whose constitutions are spoiled by debauchery
and intemperance, previous to their being attacked with this dis-
ease, who have hard livers, and anasarcous limbs, are not proper
subjects for such an operation. Hard tumors within the abdomen,
in the regions of the liver, spleen, kidneys, or mesentery, imply-
ing a diseased state of the said viscera, are very material objec-
tions to the removal of the local evil in the scrotum. In short,
whenever there are manifest appearances or symptoms of a truly
diseased state of any of the principal viscera, the success of the
operation becomes very doubtful; more especially, if such symp-
toms and appearances, upon being properly treated, resist in such
manner as to make it most probable, that a cancerous virus is the

A TREATISE ON THE HYDROCELE. 139

real cause of them. When none of these require our attention, the
object of consideration is the testicle and its spermatic vessels.
The state of the mere testis can hardly ever be any objection to
the operation; the sole consideration is the spermatic chord. If
this be in a natural state, and free from disease, the operation not
only may, but ought to be performed, let the condition of the tes-
ticle be what it may. If the spermatic chord be really diseased,
the operation ought not to be attempted. For although, on the one
hand, a probability of success will vindicate an attempt, even
though it should fail; yet, on the other, where there is no such
probability, an operation, though performed in the most dexter-
ous manner, will prove only a more ingenious method of tor-
menting.

This therefore (the state of the spermatic chord) is a matter
which may require our most serious consideration; since, on this it
is (when the disease appears to be local) that we must found our
judgment; and by this must form our resolution, either to leave a
man to the truly miserable fate of being slowly, though certainly,
destroyed, by a cruelly painful, and frequently very offensive dis-
ease; or endeavour to save, and preserve him in health and ease,
by means which have so often proved successful, as truly to de-
serve the appellation of probable.

All writers on this subject agree in saying, that if the spermatic
process has partaken of the diseased state of the testicle, that is,
has become enlarged and hardened, and such enlargement and
induration extends itself quite up to the abdominal muscle, that
the operation of castration ought not to be performed, because it
not only will prove successless, but will hasten the death of the
patient. And this is, in some degree, most certainly true; but not
without some limitation. A truly and absolutely diseased state of
the spermatic chord, in any part of it, is certainly a very material
objection to the operation, as it most commonly proves a bar to the
success of it; and a morbid state of the same chord quite as high as
the abdominal muscle, that is, of all that part of it which is exter-
nal to the cavity of (he belly, is a just and full prohibition against
such attempt. But on the other hand it must be observed, that
every apparently morbid alteration of the sperma'ic chord is not
really such; and therefore, that every enlargement, induration,

140 A TREATISE ON THE HYDROCELE

fulness, &c. which seems to alter the spermatic vessels from that
state which is called a healthy and natural one, is not to be re-
garded as a disease; at least, not as such a disease as is sufficient
to prohibit the attempt to obtain a cure by extirpation.

The difference between these, it is the duty of every practition-
er to become perfectly acquainted with, as it is from a considera-
tion' of these, that he ought to determine, whether he may, with
that firmness and assurance which the probable expectation of
success will give him, propose and advise castration, or find
himself obliged in conscience to dissuade, or refuse, the perform-
ance of it.

When the spermatic vessels are not only turgid and full, but
firm and hard; when the membrane, which invests and connects
them, has lost its natural softness and cellular texture, and has
contracted such a state, and such adhesions, as not only greatly to
exceed its natural size, but to become unequal, knotty, and pain-
ful, upon being handled; and this state has possessed all that part
of the chord, which is between the opening in the oblique mus-
cle and the testicle, no prudent, judicious, or humane man will
attempt the operation; because he will most certainly not only do
no good to his patient, but will bring on such symptoms as will
most rapidly as well as painfully destroy him. Of this there are
so many proofs, that the truth of it is inconlestible.

In some modern French books, we have indeed miraculous ac-
counts of operations of this kind, performed by dividing the tendon of
the oblique muscle, by tracing the diseased spermatic vessels with-
in the cavity of the belly, and there making the ligature and ex-
cision: but these are operations which make a figure in books
only, and are performed only by visionary writers; or, if ever they
have been practised, serve to show the rashness and insensibility
of the operators, much more than their judgment or humanity,
Whoever (notwithstanding these tales) performs the operation in
the circumstances above mentioned, will prove himself much more
hardy than judicious; and will destroy his patient, without hav-
ing the satisfaction of thinking that his attempt, though success-
less, was yet vindicable; the only circumstance which can, in such
events, give comfort to a man who thinks rightly.

On the other hand, as I have already said, every enlargement

A TREATISE ON THE HYDROCELE. Ml

of the spermatic chord is not of this kind, nor by any means suf-
ficient to prohibit or prevent the operation.

These alterations, or enlargements, arise from two causes, viz.
a varicose dilatation of the spermatic vein, and a collection, or
collections of fluid in the membrane investing and enveloping the
said vessels. In the first place, as there is no reason in nature
why a testicle, whose vessels have previously (for some time per-
haps) been in a varicose state, should not become scirrhous; so it
is also clear, that the scirrhosity seizing such testicle, ivill by no
means remove, or even lessen, such varicose dilatation of the ves-
sels from which it is dependent; on the contrary, will most proba-
bly, and indeed does most frequently, increase such distention: but
such mere varicose enlargement of the vessels, whether it be pre-
vious or consequential lo the morbid state of the testis, does not,
nor ought to prevent the removal it, if otherwise fit and right. It
is indeed an objection to the doctrine of Mr. Le Dran, and a few
other writers, who make no ligature on the chord, and trust to a
slight contusion of it between the finger and thumb for a suppres-
sion of haemorrhage; but is none to the rest of the operation, as I
can from experience testify.

In the next place, the diseased state of a truly scirrhous testicle,
its weight, and the alteration that must be made in the due and
proper circulation of the blood, through both it and the vessels
from which it is dependent, may and do concur in inducing a va-
ricose dilatation of the spermatic vein, without producing that
knotty, morbid alteration and hardness, which forbid our attempts.
Between these, a judicious and experienced examiner will gene-
rally be able to distinguish.

In the former (the truly diseased state) the chord is not only
enlarged, but feels unequally hard and knotty; the parts of which
it is composed are undistinguishably blended together; it is either
immediately painful to the touch, or becomes so soon after being
examined; the patient complains of frequent pains shooting up
through his groin into his back; and from the diseased state oi"
the membrane composing the tunica communis, such adhesions
and connexions are sometimes contracted, as either fix the process
in the groin, or render it difficult to get the finger and thumb quite
round it.

142 A TREATISE ON THE HYDROCELE.

In the other, (the mere varicose distention,) the vessels, though
considerably enlarged and dilated, are nevertheless smooth, soft,
and compressible; the whole process is loose and free, and will
easily permit the ringers of an examiner to go all round it, and to
distinguish the parts of which it is composed. It is not painful
to the touch; nor does the examination of it produce, or occasion,
those darting pains which almost always attend handling a process
malignantly indurated.

I do not say, that the distinction between these two stales is al-
ways and invariably to be made; but that it often may, I know
from repeated experience; and that the operation may safely be
attempted, and successfully be performed, I know from the same
experience. The state of a man, left to the mercy of a malignant
scirrhus, is so truly deplorable, that we cannot be too attentive in
examining the precise nature of each individual case, and in em-
bracing every opportunity of giving him that relief, which it may
at one time be in our power to give, and which, the favourable
opportunity missed, it may never be in his power again to re-
ceive.

The other circumstance which I have mentioned as capable of
deceiving an operator, and inducing him to believe that the sper-
matic chord is much more diseased than it really is, and thereby
deterring him from the performance of an operation which might
prove successful, is the extravasation, or collection of fluid in the
cellular membrane enveloping the spermatic vessels, between the
abdominal opening and the testis.

In the cellular membrane leading to a diseased testicle, it is no
very uncommon thing to find collections of extravasated fluid.
These, as they add considerably to the bulk, and apparent size, of
the process, make the complaint appear more terrible; and, as I
have just said, less likely to admit relief.

When this extravasation is general through all the cells of the
investing membrane, and the spermatic vessels themselves are
hardened, knotty and diseased, the case is without remedy; for
although a puncture, or an incision, will undoubtedly give dis-
charge to some, or even the greatest part of the fluid; yet this ex-
travasation is so small, and so insignificant a circumstance of the
disease, and the parts in this state are so little capable of bearing

A TREATISE ON THE HYDROCELE. 143

irritation, that an attempt of this kintl must be ineffectual, and may
prove mischievous.

But on the other hand, collections of water are sometimes made
in the same membrane, from an obstruction to the proper circula-
tion through the numerous lymphatics in the spermatic process,
while the vessels themselves are really not diseased, and therefore
very capable of permitting the operation. In this case, the fluid is
generally in one cyst, or bag, like to an encysted hydrocele, and
the spermatic chord, cyst and all, are easily moveable from side
to side; contrary to the preceding state, in which the general load
in the membrane fixes the whole process, and renders it aimost
immoveable.

A discharge of the fluid will, in this case, enable the operator
to examine the true state of the process, and, as I have twice or
thrice seen, put it into his power to free his patient from one of
the most terrible calamities, winch can befal a man.

There is one more circumstance relative to the scirrhus testicle,
which appears to me to be worth attending to, as I cannot help
thinking, that it has misled many, who have not had sufficient
opportunity of comparing theory with practice.

It has been confidently asserted, and is generally believed, that
a scirrhus testicle never begins in the epididymis of the said tes-
ticle. The consequence of this doctrine is, that when a disease,
which affects a testicle, by enlarging and hardening it, makes its
first attack on the epididymis only, such disease is not allowed to
be a scirrhus, nor permitted to be treated as such.

That inflammatory kind of tumor, which, in the virulent go-
norrhoea, seizes the testicle, and is called the hernia humoralis,
affects the epididymis; and, even under the best care, sometimes
leaves it too large, and too hard. This is said never to end in, or
produce a scirrhus; and I do not recollect that I have ever known
it to do so. The disease, which consists in an induration and en-
largement of the whole testicle, in the more confirmed lues, affects
the epididymis also, as well as the glandular part of the testicle;
and I do not remember to have seen it either become cancerous,
or not yield to mercury, properly administered. But that a true
scirrhus, or cancer, sometimes makes its first attack on the epidi-
dymis, which it alters or spoils, before it at all affects the testicle,

144 A TREATISE ON THE HYDROCELE.

is a truth, of which I have not the least doubt. Among others, I
formerly believed the contrary doctrine; and, in the first edition of
this book, have given it as my opinion; but I am, from experience,
so perfectly convinced of the truth of what I have now asserted,
that I think myself obliged to declare it. The mistake I suppose
to have been made by the first propagators of this opinion, thus:
The hernia humoralis, and the venereal sarcocele, always enlarge
the epididymis, and generally leave it somewhat too hard: both
these have, by adventurous and unknowing people, been mis-
taken for scirrhi: but it being found, by experience, that these
alterations in the epididymis, Avere either totally removed by me-
dicine, or, if any part remained, it continued harmless through
life, an inference was drawn, that, as true scirrhi are not often
either removed by medicine, or continue harmless, therefore an
original affection of the epididymis could never be a true scirrhus —
a deduction, which the premises do not by any means authorise;
and which I am satisfied is not true.
The operation of castration is performed as follows: —
The patient being laid on a table of convenient height, the in-
teguments covering the spermatic vessels in the groin are to be
divided. This incision should be begun, as nearly as can be,
opposite to the opening in the abdominal muscle, and should be
continued a good way down the scrotum.

The manner of beginning this incision is differently described
by writers; some of them advising that the skin be held up by an
assistant; others that the knife be used perpendicularly, in this as
in other parts. It is indeed a matter of no importance at all,
either to patient or surgeon, and therefore may very safely be left
to the choice of the latter; but the length of the division is of con-
sequence to both. A small wound will indeed serve to lay bare
the spermatic chord, but it will not permit the operator to do what
is necessary afterward, with dexterity or facility: a small wound
gives as much pain in the infliction as a large one; and, as the
scrotum must, first or last, be divided nearly to the bottom, it had
better be done at first, on every account. The spermatic chord,
thus laid bare, is to be freed from its surrounding membranous
connexions; and then the operator, with his finger and thumb
separating the blood-vessels from the vas deferens, must pass a

A TREATISE ON THE HYDROCELE. 145

needle, armed with a ligature, between them; and having tied the
former only, must cut through or divide the whole chord at a quar-
ter or half an inch distance from the said ligature, according as
the state of the process and testicle will admit. This done — he
is then (with the same knife, with which he has performed the
former part of the operation,) to dissect the testicle out from its
connexion with the scrotum: the loose texture of the dartos, the
previous separation of the testicle from the spermatic vessels, and
the help of an assistant to hold up the lips of the wound, will ena-
ble him to do this with very little pain to the patient, and great
facility to himself. 1 '

If any considerable artery bleeds, either i« the scrotum or in the
dartos, it must be restrained by ligature; and when that is done,
the void space in which the testicle was, is to be very lightly filled
with soft dry lint; q Which lint should be suffered to remain until it

P This circumstance of cutting off the testicle, before it be dissected out
from the scrotum, immediately after the ligature has been made, is of more
consequence to the patient's ease, as well as to the facility and expedition of*
the operation, than they who have not tried it are aware of.

1 Lint, however soft and lightly applied, acts as a foreign body, and pre-
vents the immediate union of the wound. Our present method, and which
Mr. Pott practised since his publication of this work, appears to be a consi-
derable improvement on this part of the operation t— When the testis is re-
moved, and the bleeding vessels of the scrotum, if there are any of conse-
quence, are secured, no lint, nor dressing of any kind, is introduced ; but
the parietes of the wound are brought together and retained by ligatures,
more or fewer, according to the extent of the wound, as, from the moisture
of the parts, sticking-plaster cannot be depended on : these ligatures should
be tied with slip-knots, that they may be loosened, without a necessity being
induced of removing them, in case of any fresh haemorrhage, which some-
times happens after the patient is warm in bed. Dry lint is then applied,
and kept on by a simple dressing, avoiding every thing greasy on the edges
of the wound : by these means the parts unite and heal in great measure by
the first intention ; or, if any collection of matter is formed in the cavity which
the testis occupied, it will be in small quantity, and easily discharged by the
lower part of the wound, which must form a depending and an advantageous
opening; after which the granulations will gradually fill the space, and the
cure will be but little retarded. This excellent plan of preserving as much
sound and undiseased skin as possible, and putting no obstructions in the way
of Nature's healing powers, has of late years been applied to almost every
species of tumor which it may be necessary to remove, and may be esteemed
one of the greatest improvements of modern surgery. E.

VOL. II. T

14G A TREATISE ON THE HYDROCELE.

be perfectly loosened by the suppuration from every part of the
sore. If it be removed sooner, it must be clone by force: in
which case, it will give unnecessary pain, and leave a crude, un-
digested sore; if it be not removed until quite loose, it will give
no pain, and the sore will be found clean, and well digested, and
requiring no other dressing afterward than mere dry lint; which,
from this time, should be applied in such quantity and manner, as
to give Nature an opportunity of contracting and healing the wound
as fast as she can; in both which, she may be considerably assist-
ed by the judicious exhibition of the bark.

I am very sensible, that in the above direction for the perform-
ance of the operation ef castration, I have differed from the doc-
trine of some very eminent modem practitioners; and particularly
from Mr. Le Drain.

No man thinks more highly of Mr. Le Dran's abilities than I
do; but, in these matters, every one must take the liberty of judg-
ing for himself; and I cannot help thinking, that I have good rea-
son for my opinion.

Mr. Le Dran, having divided the integuments in the groin and
scrotum, separates the testicle from the surrounding membrane
with his fingers, and with scissors. This method is rather coarse,
is unnecessarily painful, and does what must for ever be wrong —
multiplies the instruments to be used, without any necessity. The
knife, in the hands of any man, at all accustomed to the use of one,
will execute the whole with more apparent dexterity, with less
pain, and much greater expedition/

I have, without hesitation, directed the spermatic chord to be

r " Je fens le scrotum jusqu'au dessous du testicule malade, et avec mes
" doigls je detache le testicule d'avec le tissu cellulaire, qui le tient attache
"dansle scrotum. Si quelque portion membraneuse a de la peine a se de-
tacher, je la coupe avecdes ciseaux." Mr. De Garengeot divides the whole
scrotum with scissors ; and I cannot say that I have not seen it done in Lon-
don : but it is a tedious, coarse, cruel, and very unhandy method of doing it.
" Cette premiere incision faite, Poperateur poussera de force le doigl indice,
*« ou le grand doigt, sous la peau, dans les cellules graisseuses, afin d'entrer
" dans le scrotum, et il aggrandira son incision, en coupant sur son doigt avec
"des ciseaux mousses la peau, qu'il aura separee des graisses, et il ouvrira
" ainsi tout le scrotum."

Garekgeot, Opehat. Cam

A TREATISE ON THE HYDROCELE. 147

tied. Mr. Lc Dran's advice is different. He advises, that a liga-
ture be passed underneath it, and left there to be tied; or not, as
occasion may require.

He then takes the extremity of the latter between his finger and
thumb; and, by rubbing, pinching, or bruising, produces a degree
of contusion sufficient (as he thinks) to prevent, in general, any
haemorrhage; and, having so done, he cuts off the testicle from the
said chord, immediately below the bruised part, leaving (as I said
before) the ligature ready to be tied, if necessary. 8

This method of first bruising, and then cutting off, the spermatic
chord, without making a ligature on it, is also prescribed and
practised by some gentlemen of eminence here; and I make not
the least doubt, that, both with these gentlemen, and with Mr.
Le Dran, it may have been successful; but, as I have seen three
people lose a very alarming quantity of blood, and one very nearly
his life under it; and as in the many times which I have performed
this operation, I never saw the least inconvenience arise from the
ligature, I cannot approve the omission of it. 1

Mr. Le Dran himself not only seems to be apprehensive of
what may be the consequence, by his passing a ligature, and leaving
it ready to be tied, and by the very good reason which he gives

c " 11 n'y a que Partere qui m'interesse, parce qu'il n'y a qu'elle qui puisse

'* dormer du sang apres que j'awrai coupe le cordon. Je la prends entrc

«« deux doigts, a 1' endroit ou elle passe sur'Pos pubis, et avec elle les veines

" qui l'entourent ; puis je passe entre ces vaisseaux et le canal deferent, que

" Ton distingue sous le doigt, a sa duret£, une aiguille, enfilee de deux brins

«« de fil cire. ■ J'ote Paiguille, et je laisse les fits, pour faire la ligature.au cas

** qu'elle devienne necessaire. Je prends aussitot les vaisseaux plus bas que

" l'os pubis, etje le froisse entre mes doigts, pour y faire une espece de

" contusion ; puis je coupe le cordon un peu au dessous de cette endroit

" froisse."

M. Le DnAK.

« That it would be in the highest degree dangerous to omit securing the
spermatic artery, is now universally acknowledged; but as tying the chord
(notwithstanding the vas deferens is left out) is by far the most painful part
of the operation, it has been the practice of many good operators to' dissect
down to the vessel, and to put a ligature round it, by a needle ; or, if the
vessel be divided by means of the forceps, without including any surrounding
parts ; then to divide the remainder of the chord, and finish the operation
in the usual manner. E.

148 A TREATISE ON THE HYDROCELE.

for not cutting off the spermatic chord (as most of his countrymen
advise) close to the opening in the tendon of the oblique muscle;
but also in the same paragraph acknowledges, that a fatal haemorr-
hage has been the consequence of the ligature having slipped off,
after it has been made. u

In the case of a perfectly sound and unaltered spermatic chord, in
winch the vessels are not become varicose, and the operator can
make his division of them as low as he pleases, this froissement,
this contusion may be sufficient to prevent an haemorrhage; but in
cases where the spermatic chord is enlarged, Mr. Le Dran himself
does not think it safe to trust to it. And that the vessels from which
a scirrhous testicle is dependent, may be considerably enlarged
and distended, and that pretty high, and yet not so diseased as to
render the operation unadviseable or unsuccessful, I have more
than once or twice seen. The compression which may be made
of the extremity of the divided chord against the os pubis, on which
some stress seems to be laid, will, whether it be made by the ringer,
or by compress and bandage, prove more troublesome to the patient
than the very momentary pain of the ligature.

u " On demandera, pourquoi je ne fais pas la ligature du cordon immedi-
" atement au dessous de ''anneau, comme les auteurs le prescrivent. Je
" reponds, que, si la ligature s'echappe, on ne pent plus lier l'artere, qui se
" retire au dessus de l'anneau, ou elle peut donner du sang dans le tissu
" cellulaire du peritoine, et faire perir le malade, comme I' on a vu arriver."

Le Dhax.

" Si le cordon spermatique est gonfle" jusque' aupres de l'anneau, on ne
" peut suivre cette methode; et il faut absolument faire la ligature du cordon,
" immediatement au dessous de l'anneau" The remainder of this paragraph
does indeed seem a kind of contradiction of the preceding. " S'il est tres
" gonfle meme un plus haut que l'anneau, et qu'on ne puisse se dispenser de
" faire l'operation, il n'y a point de ligature a faire ; il faut fendre un pcu
"l'anneau, puis couperle cordon, et l'artere ne donnera pas de sang." Set
aside all considerations of the propriety or impropriety of performing the
operation, when the spermatic chord is diseased above the ring, (as it is
called,) what can be the reason why the artery should not be expected to
■bleed, after being divided within the abdomen ? when the same gentleman
allows it to have produced a fatal hemorrhage, upon retiring into that cavity,
or into the cellular membrane of the peritioneum, after having been cut off
without the said ring.

A TREATISE ON THE HYDROCELE. 149

The last circumstance in which I have ventured to differ from
the commonly prescribed rules, is, that I have not advised the
removal of any part of the scrotum. 5

My reason is, that I never found it necessary, in any case, when
the scrotum was not adherent to the testicle.

Let the size of the scirrhus be what it may, the scrotum will
corrugate to its natural form, when the wound is healed; and if in
the operation it fairly be divided to the bottom, will neither lodge
matter during the cure, nor produce any inconvenience afterward.

When it is adherent to the testicle, and the cellular structure of
the dartos is thereby destroyed, all such adherent part should cer-
tainly be removed; not only because it is diseased, but because it
will give the patient a great deal of unnecessary pain to dissect it:
but then it should always be removed along with the testicle, in the
manner directed by Mr. Samuel Sharpe, and not be dissected off
first, and removed afterwards.

By the latter method, the patient's pain is increased, prolonged.
and even renewed, without the least necessity.

In every operation in which a considerable portion of skin is to
be divided, and particularly in this, and the amputation of womens'
breasts, it should always be remembered, that, as the division of
the skin (the general organ of sensation) is the most acute and
painful part of what is done by the knife, it cannot be done loo
quick, and should always be done at once: the scrotum should
always be divided to the bottom, and the circular incision in the
skin of a breast always made quite round, before any thing else
be thought of. y If this be not executed properly and perfectly,

x " Si quelque portion membraneuse a de la peine a se detacher, je la'

" coupe avec des ciseaux; et guand le testicule est ote, j'enleve une partie de

" la peau du scrotum, si cette peau s'est trop dtendue par le volume dc la

" tumeur."

Le Drax.

The same direction is given by Laur. lleister. " Cutis scroti quae exempt*
" testiculo supervacanea ut resccari forfice debet." By which means (that
is, by not removing the skin along with the testicle, but afterward) the patient
suffers almost as much pain as the whole operation, properly performed,
would occasion ; and that without any necessity.

y This passage has been quoted as a proof that Mr. Pott'susual practice was
to remove the whole skin covering a cancerous breast; but it could only

150 A TREATISE ON THE HYDROCELE.

the operation will be attended with a great deal of pain which
might be avoided, and the operator will be justly blameable.
* Before I take my leave of this operation, I think it right to give
the young practitioner a caution, viz. that if the tumor be of a pyri-
form figure, perfectly smooth, and equal in its surface, and free
from pain, notwithstanding the degree of hardness may be great,
and he may, in his own opinion, be clear that the tumor is not
produced by water, but is a true scirrhus, I would advise bim,
immediately previous to the operation, to pierce the anterior part
with a trocar, in order to be certain. My reason for giving this
advice is, that I was once so deceived by every apparent circum-
stance of a true, equal, indolent scirrhus, that I removed a testicle,
which proved, upon examination, to be so little diseased, that, had I
pierced it with a trocar previous to the operation, I could, and cer-
tainly should have preserved it.

Having, in the immediately preceding pages, given my opinion
very explicitly concerning the expediency and propriety of re-
moving, by the operation of castration, a scirrhous testicle, when
fairly characterised, and properly circumstanced, it cannot be
necessary to relate any such cases. Every man, who is at all con-
versant with this kind of business, knows, that the operation on
proper subjects, and in proper instances, is very frequently suc-
cessful; and that many people have been by it rescued from imme-
diately impending misery, and have passed many years in health
and ease, and in a state to propagate their species.

Particular accounts of such, would appear like mere boasiings
of success.

Those, therefore, which follow, are selected, either because the
fortunate event was not very probable; and they may therefore
serve to prove, that we should not too hastily or inadvertently
despair:

Or, because their true nature was mistaken; and, therefore,
they were improperly treated:

relate to those cases in which the skin was fixed to the gland, and partook
of the disease. When it was sound and unaffected, Mr. P. by his doctrine and
practice inculcated the preservation of :t; and I have many times seen him
remove large tumors by means of a simple line, so as to preserve the skin
entire. E.

A TREATISE ON THE HYDROCELE. 151

Or, that they were attended with circumstances not to be fore-
seen or prevented:

Or, that the case was too long neglected, and the operation too
long deferred; or performed when success from it was not at all
likely:

Or, that they were combined with other complaints, either
general or local, by which the best calculated attempts must be
frustrated:

Or, that they contain something in their nature which appears
to be singular. From each, or all of which, 1 apprehend the
practitioner may reap full as much, if not more, beneficial instruc-
tion, than from the most pompous histories of success.

CASE XXXIX.

A man about forty-seven years old, who had been, for the
space of three or four years, afflicted with a truly scirrhous testicle,
applied to me. He had been more than once, during that time,
advised to part with it, but was afraid of the operation. He was
now alarmed by an alteration which it had lately undergone, and
from some circumstances in his general health which were new.
The tumor, from its first appearance, had been indolent and equal,
the spermatic chord in a natural state, and he had no other com-
plaints of any kind. The testicle was now very unequal in its
surface; it had increased considerably within the last three months;
and the spermatic chord was enlarged; that is, become varicose,
more than halfway from the testicle to the groin. He had also
a colicky disorder, which recurred frequently, without any purg-
ing.

The case was unfavourable, and there appeared to me to be no
chance, but from castration. The state of the spermatic vessels
rendered that dubious; but the improbability of the disease remain-
ing in its present state, made it still worth embracing. The gene-
ral state of the patient's health was also an alarming circum-
stance; but neither could that be amended, while the local disease
remained.

152 A TREATISE ON THE HYDROCELE.

Having apprised him of all these circumstances, he willingly
submitted to the operation; which was performed the nexi day.
The state of the process just admitted of making the ligature
between the enlarged part and the abdominal muscles. Nothing
particular attended the cure: the sore healed very kindly, and the
man has enjoyed a good state of health ever since; which is now
between four and five years.

CASE XL.

A gentleman from America applied to me, on account of a
complaint in one of his testicles. It had, while he was abroad,
been supposed to be, and had been treated as, venereal; by which
means, what was, at first, a simple, equal, indolent scirrhous, with
a spermatic chord unaltered from a natural state, was, when I
saw it, unequal, at times painful, and dependent from spermatic
vessels, considerably enlarged and swollen, though still soft, and
free from knot or induration. He was otherwise in perfect health,
his age thirty-three, and his constitution unhurt by debauchery or
intemperance.

With regard to the testicle, there could be no doubt, either of
the nature of the disease, or the propriety of its being removed;
but the state of the spermatic vessels was such, as made the pros-
pect of success from castration very uncertain. Two or three
consultations were had, the result of all which were nearly the
same; that is, the surgeons were very apprehensive of the opera-
ration, from the state of the chord, and therefore would not press
it; and the physicians prescribed internal remedies; and among
these the cicuta, which luckily happened to disagree so much
with the patient, that he would not go on with it: — I say luckily,
because it thereby prevented the loss of more time in the use of it.

The patient was single, a sensible man, and had a great deal
of courage and resolution in his natural constitution.

Having maturely weighed all that had been said to him, and
finding that no relief was likely to accrue from medicine, and that
his disease was as little likely to stand still, he determined rather

A TREATISE ON THE HYDROCELE. 153

v

to take the chance which the operation would give him, either of
sudden destruction, or a cure, than live in that state of anxiety,
which must arise from a constant meditation on the nature of his
disease.

The operation was performed; and in the execution of it, I was
particularly attentive to the state of the vessels. The whole pro-
cess was, I may venture to say, full double the size it ought to be,
and the veins very tortuous, by their being distended; but there was
no induration, nor any inequality, save that proceeding from the
varicose state of them.

When the testicle was removed, I examined that also very care-
ful'y. The cavity of the tunica vaginalis was, in a great measure,
abolished by an almost general adhesion of that membrane with
the albuginea; the epididymis was tolerably sound; but the whole
compages of the testis hard and diseased; and in the very centre
of it was a putrid slough, and a very small quantity of ill-colour-
ed sanies.

It is now above five years since the operation. The patient
has enjoyed perfect health ever since, and finds no one inconve-
nience from the loss of the part.

In these two cases, the event was fortunate beyond expectation.
In such circumstances, every thing is to be feared: the operation
is seldom advisable, because seldom successful. However, they may
stand as instances to prove that where there is even a small foun-
dation for hope, it is better to embrace such opportunity, than to
leave the patient to his fate. Neither himself nor his friends should,
in such case, be flattered or deceived; but the uncertainly should
be laid before them, and the operation should be their own choice.

CASE XLI.

A young man, about twenty-four years old, desired my opi-
nion concerning a testicle, which was beginning to enlarge, and
was already become very hard.

The account he gave was as follows: —

That, about seven or eight months before, h.e had a common
vol. ii.. u

154 A TREATISE ON THE HYDROCELE.

lnrnia humoralis, in consequence of the suppression of a gonor-
rhoea by hard riding. That the inflammatory symptoms were
soon removed by rest, evacuation, and proper application; but that
neither the testicle, nor the epididymis, had ever returned to their
natural size. That the surgeon, whose care he had been under,
had, since the inflammation was gone off, given him a consider-
able quantity of mercurial medicine internally, and had rubbed on
a good deal of the ointment externally; by which his mouth had
been made sore; and that he had also taken two or three mercurial
vomits.

The tumor was perfectly indolent, even upon being handled;
it had a stony, incompressible kind of hardness; and the sperma-
tic vessels were in a sound natural state.

I told him, that whatever might have given rise to his disease,
it was my opinion that it was a true scirrhus; that it would never
be cured by medicine; that, although it was quiet, and free from
pain now, no man would pretend to say how long it might con-
tinue so; and that I should, by all means, advise him to part with
it in its present state, rather than stay till such alteration should
be made in it, as, though it might induce him to comply, might
render the operation unsuccessful. He disapproved my advice,
and I saw no more of him for hear four months; at the end of
which time he called upon me again.

His testicle was a good deal increased in size, but the sperma-
tic chord still unaffected.

I repealed my former advice, and he again refused to comply.
At the distance of two months from this time, I saw him again.
His testicle was still more enlarged, and the cavity of the tunica
vaginalis palpably contained a fluid. He said, he had showed it
to two other surgeons; both of whom had promised him much
relief, if not a cure, by letting out that water, which they told him
made the principal part of his disease. I answered, that I had
no manner of doubt that there was a fluid; but I apprehended it
to be much less, in quantity than either he, or they who had pro-
mised a cure by letting it out, took it to be; that it appeared to me
to make so small a part of the swelling, that I was sure that the
decrease of size, upon its discharge, would bear no proportion to

A TREATISE ON THE HYDROCELE. 155

to his expectation; that this fluid made no part of the original dis-
ease, but was an accidental consequence; that an opening made
into a testicle so circumstanced might excite very disagreeable
symptoms, from which he was at present free; and that my opi-
nion was still, that it ought to be totally removed, or not meddled
with.

He left me with much dissatisfaction. lie said, that I was
too tenacious of my own opinion, and too regardless of that
of others. But I had seen too many of these cases, to be in
any doubt concerning its nature; and I knew the people, under
whose direction he then was, too well to suppose, either that
they knew any thing of the matter, or that they would leave
any thing unattempted, while he had either credulity or money.
Soon after this I heard that he had submitted to have a punc-
ture made, by which a very small quantity of bloody serum
was discharged; but the size of the tumor so little lessened,
that his operator would fain have thrust a lancet in again, and
deeper; but this the patient would not permit.

Being vexed at what had happened, he came not again to me,
till at the distance of near two months more. He was now in a
very different state. His complexion was wan and pale, his flesh
and appetite gone, his testicle very large, unequal and painful;
and the spermatic chord diseased quite up to his groin. I was
very sory to be obliged to tell him, that I could do him no good;
and that the operation was by no means advisable.

He now, of course, fell into the hands of those who only want-
ed a little ready money; and having tried two or three of these,
he was advised to lake the cicuta; which he did for some time, and
in large doses, but (as usual) without any real or permanent good
effect.

His state, soon after this, became truly deplorable; his testicle was
of an amazing size; the spermatic chord, quite up to his belly, so
large as hardly to be capable of being grasped by the hand; a very
large, hard tumor within that side of the belly; his pain acute and
constant; and his flesh, strength, and appetite, totally gone.

In these circumstances, a believer in the omnipotence of the
sublimate solution, prescribed it for him; from which he receiv-
ed the advantage of having his death hastened.

156 A TREATISE ON THE HYDROCELE.

CASE XLII.

A man about thirty, of a full plethoric habit, showed me a tu-
mor in the spermatic process, about the midway between the
groin and testicle: it was hard, circumscribed, indolent when not
meddled with, but painful for a long time after having been han-
dled, and the pain of such kind, as lo indicate the disease not to
have a very benign character; the testicle was perfectly free.

I advised the loosing some blood, gentle evacuation by stool,
the use of a suspensory to take off the weight, and desired the pa-
tient to let me see him again in about ten days. At the distance
of somewhat more than a month, he came to me again; and told
me, that from me he had gone to a rupture-doctor, who put a truss
on him, and giving him an external application, bade him come
to him again in a week; that the pressure of the truss, joined to
the irritating quality of the ointment, greatly increased the pain
and the swelling; that his doctor then applied an adhesive plaster,
and when he had worn that a few days, he thrust a lancet into
the body of the tumor; that nothing followed the lancet but
blood; that he enlarged the opening, and filled it with lint; and
that for several days after, he had dressed the sore with red pow-
der (precipitate). He had now as truly malignant a cancerous
sore as I ever saw; and all the spermatic process above it was so
diseased, as to prohibit all thought of an operation. Nothing
palliated the fury with which it proceeded; he lived several months
in great and constant pain, having a large hard, body within the
belly (on that side,) extending from the groin quite up to the re-
gion of the kidney; and which I make no doubt, consisted of the
diseased spermatic vessels.

CASE XLIII.

A man, about forty-eight years old, who lived at some consider-
able distance from London, perceived one of bis testicles becoming

A TREATISE ON THE HYDROCELE. 157

hard; larger in size than it used to be; and when he was on horse-
back, somewhat painful. m

Having several times had a gonorrhoea, and twice been confined
with a hernia humoralis, he thought that this swelling was of the
same kind, and applied to the apothecary of the town where he
lived; who, not being much accustomed to surgery, and being
misled by the patient's opinion and account, looked on it in the
same light, and gave him several doses of calomel: these not
succeeding to his wish, he confined the patient to his bed, applied
a poultice to the scrotum, and vomited him twice or thrice, with
the mercurius emet. flavus. By this process the man became fe-
verish; lost his appetite, sleep, and flesh; and the testicle increas-
ed, both in size and hardness.

I was now consulted by letter, and gave my opinion, that the
case was not venereal; that mercurial medicines, or whatever was
likely to increase the circulation, were wrong, and would be found
prejudicial; that whatever might become necessary hereafter, the
present intentions ought to be, to procure ease, to remove the fe-
ver, to keep the body (which had always been costive) gently
open, and to acquire strength by the administration of soft, light
nourishment; and I recommended the decoct, sarsaparilla;, with
milk, for his common drink.

In another letter, which I received at about three weeks' dis-
tance from the first, my opinion was asked concerning the cicuta:
to which 1 replied, that in scirrhous and cancerous cases (one of
which I took this to be) I had never yet s^en it do any good,
though taken for a considerable time, and in large doses; but, on
the other hand, as I had never seen it do any harm, I could have
no objection to its being tried.

In about two months, or a little more, I had another letter, giv-
ing me an account that the cicuta had been taken freely, and had
also been constantly applied as a cataplasm; that, in about a month
after its first application, the pains, both in the part and in the
patient's back, were remarkably increased; that he now and then
complained of being chilly; and that there had been, from
about that time, a palpable fluctuation of a fluid, near to the
surface of the tumor; that this fluid had been let out by the
point of a lancet, and proved to be only a small quantity of a

158 A TREATISE ON THE HYDROCELE.

bloody serum; that, from the time this opening had been made,
the pain as well as the side of the tumor had increased; that, by
continuing the cicuta poultice, with the addition of some Burgun-
dy pitch, a collection of matter, or imposthumation, was now pro-
duced, plainly (o be felt, though deep in the body of the testicle;
and I was desired to say what I thought would be the properest
manner of giving discharge to it.

I returned answer, that it Avas a very disagreeable thing to be
obliged to give a positive opinion on a case by relation only; and
that from those who I was sure thought not of it as I did. That as
it was by no means unlikely that I might be mistaken, I desired,
that what I should now say might not be understood or applied to
any other case, than what / took this to be; that I took it to be a
scirrhus, which was becoming cancerous apace, and would very
soon show more of its malignant disposition; especially if irritated.
That the fluid, which had been let out, was nothing more than
the water of the tunica vaginalis, whose absorption was prevent-
ed; and whose colour was produced by the diseased state of the
testicle. That I should not have advised the letting it out at all;
much less in that small quantity. That it was my opinion, that
the fluid, which was now supposed to be felt to fluctuate deep in
the body of the testicle, was by no means matter, or the effect of
a kindly suppuration; but a malignant sanies, the consequence of
the very diseased state of the testis. That I did verily believe
they would find, that the quantity of it bore small proportion to
the size of the general tumor That the letting it out would more
probably occasion an aggravation than an alleviation of symptoms,
and render the disease still more painful and more hazardous than
it was already. And that I should not be surprised to hear, that
there was no fluid at all.

To this I received a short reply, signifying that it was appre-
hended I had mistaken the case. That another gentleman in
London had been consulted, who (from the account given of the
state of the spermatic chord, of the preceding hernias humorales,
and, most probably, from a misrepresentation of the case) had ad-
vised the making an opening by knife; which had been done; but
the writer of the letter did not say a word about what was let
out.

A TREATISE ON THE HYDROCELE. 159

1 heard no more of the case, or patient, for near another month;
and then was sent for, one evening, to an inn in this town, where
I found him in a situation truly deplorable. The testicle was
amazingly large, and one half of it covered by a prodigious fungus,
which was intolerably painful, gleeted largely, and at times bled
profusely; the spermatic process was also very large, and a tumor
plainly to be felt within the belly, caused by the diseased state of
the seminal vessels. The man's strength and flesh were exhaust-
ed; in short he was dying, and did not live above a week or ten
days from this time.

I believe it must be unnecessary for me to observe, that the
misconception of the nature, and the method of treating the three
preceding cases, had no small share in contributing to the suffer-
ings of the patients, and to the fatality of their events. I believe
also, that most practitioners who have been conversant with this
kind of business, will be of opinion that the operation, performed
in due time, would certainly have contributed to the ease, and
perhaps to the preservation of them.

A cancerous disposition in the habit will certainly render a
patient liable to be destroyed, by the diseased state of parts out of
our reach; and thereby render the operation, although performed
in due time, in the best manner, and under the most favourable
apparent circumstances, unsuccessful; but as this very often can-
not be foreseen, or foreknown, surely it must be very wrong to
omit doing what may preserve health and life, only because it
may also happen, that it may do neither. In all these cases, a
guarded prognostic should be made; and it should be considered,
that though we are sometimes deceived and frustrated by sinister
events, yet, on the other hand, it happens, and that not infre-
quently, that cases which have even an unfavourable and threaten-
ing aspect at first, come to a very happy issue.

CASE XLIV.

A man, about fifty years old, desired my advice concerning a
diseased testicle. It was about the size of a small pomegranate,
very hard, perfectly free from pain, and the spermatic process

160 A TREATISE ON THE HYDROCELE.

free from all appearance of disease. Castration, he said, he was
determined not to submit to; and only wanted to know, whether
I could put him into any other method of getting rid of his dis-
ease. I gave him my opinion very freely, on the great improba-
bility of his being served by any other means; and though I did,
in some degree, advise him to submit to the operation, yet there
were some circumstances in his general health, which induced
me not to press it; and made me rather pleased, that he was pre-
viously determined against it. He had a very sallow diseased
complexion, a general want of muscular flesh and firmness; a very
frequent colic, sometimes attended with a threatening diarrhoea,
and sometimes with an obstinate constipation. In the space of
two or three years, he took a great variety of medicines, and saw
a great number of practitioners, both regular and irregular, but
found no benefit; neither did the testicle in all that space of time
suffer any material alteration, or the process become at all affect-
ed. He died of an obstinate and painful dysentery; and when
he was opened, his mesentery was found full of large, hard, scir-
rhous knots; all the lymphatic glands about the receptaculum
chyli, and beginning of the thoracic duct, remarkably diseased;
and the liver much enlarged and hardened.

The want of an healthy appearance, the pains, and other com-
plaints which attended the man, might have been owing to causes
independent of his scirrhus testicle; and upon such supposition,
the removal of the said testicle by the operation might have been
vindicable; but if it had been done, it should have been under
a very guarded and doubtful prognostic.

CASE XLV.

A man about fifty, showed me a large, diseased testicle, which
he said had been gradually, for near four yeais, getting to that
size and state; and was produced, as he thought, by the kick of a
child.

The surgeon who attended his family had often seen it, while
it was small, equal, and free from pain; and had as often pressed

A TREATISE ON THE HYDROCELE. 161

him to part with it; but while it was easy, he would never think
of it.

It was now large, and unequally hard; it had, in some parts of
it, a quantity of fluid, in others none; it was very painful to the
touch; it gave him great uneasiness in his back, from its weight;
and even while it was suspended, or he was in bed, he had such
and so frequent darting pains in it, as to render him very unhappy,
and to deprive him very much of his natural rest. The spermatic
chord was perfectly free; but the frequency of his pain, and the
disturbance of his sleep, gave him a very unhealthy appearance. I
told him, that I thought he had missed the most favourable oppor-
tunity, by not submitting to the operation while the testicle was
small, smooth, and indolent; that some circumstances in his gene-
ral state and habit were unfavourable; but still, as the spermatic
process was free, and as there was no great probability that the
testicle would ever again be easy, or cease to increase in size un-
til the spcrmatics should become diseased also, I thought it was
better to take the chance of the operation, than submit to that
certain misery which must attend the further progress of the dis-
ease.

The patient consented; the operation was.performed; and every
thing went on in the most favourable manner, till the sore was re-
duced to the size of a sixpence; he was then seized with a pain in
his belly, the sore changed its aspect, and from appearing to be
almost healed, it fretted, became foul, spongy, and spread so con-
siderably, that in a fortnight's time it was as broad as a hand; it
bled frequently, gleeted largely, was extremely painful, and very
offensive; nothing that was done had any good effect on it; and,
having languished some months, he died.

Some of the circumstances in this case were undoubtedly un-
favourable; but I have seen people do very well under similar
ones; and I still think, that the patient chose the lesser of the two
evils, and embraced the more probable chance.

vol. ir. \

1G£ A TREATISE ON THE HYDROCELE,

CASE XLVI.

A poor man, who was in St. Bartholomew's hospital for a hurt
in one of his legs, desired me to look at his scrotum, which was
of a very large size.

The tumor was principally formed by water in the tunica vagi-
nalis testis: but, through the fluid, it was easy to distinguish a dis-
eased testicle. He complained of uneasiness from the weight,
and had, he said, now and then a pain shot up from the tes-
ticle into his back; he had also, now and then, a colic, with
nausea and inclination to vomit; and was very subject to a sort
of strangury. I drew off near a wine quart of a yellow thin
fluid, by means of a trocar; and when that was done, was so satis-
fled that the testis was diseased, that I would have immediately
removed it; but the man would not consent. He soon got well of
his leg, and was discharged from the hospital. '

He was a bricklayer's labourer; and in about a fortnight or
three weeks' time from his discharge, fell from a high scaffold,
and was so much hurt that he died, after he had been again in the
hospital two days; and I gladly embraced the opportunity of ex-
amining his dead body. The tunica vaginalis was not only much
distended, but considerably thickened. The testicle was a great
deal too large and too hard; but, upon division, did not show any
considerable mark of disease, except in its very centre, where
there was a small quantity of discoloured sanies, and a putrid
slough. The spermatic vessels were not at all altered from a na-
tural state, except that the vein was varicose. Immediately below
the emulgent vessels, on the right side, was an irregular tumor,
near as big as the kidney itself, perfectly scirrhous, and firmly
attached both to the renal blood-vessels, and to the aorta. The
external part of this tumor was rough and unequal, and of a whit-
ish colour; and in the centre of it were exactly the same appear-
ances as within the testicle, viz. a small quantity of matter, and a
slough.

Where the ureter was crossed by this tumor, it was much com-
pressed and straitened in its diameter; but below this stricture it

A TREATISE ON THE HYDROCELE. 163

was considerably dilated. The kidney was not quite healthy in
its appearance.

Had this man been castrated, I make no doubt that his inter-
nal scirrhus would have destroyed him; but that was a circum-
stance not to be collected from his general state, or from his com-
plaints; and therefore not to be foreknown. The operation would
therefore have been vindicable, though unsuccessful.

CASE XLVII.

A middle-aged man, was brought into St. Bartholomew's hos-
pital for an accidental hurt of which he soon got well; and when
he was going to be discharged, he desired Mr. Freke, whose pa-
tient he had been, to look at one of his testicles. It was large,
and unequally hard; gave him a great deal of pain at short inter-
vals; and seemed to contain a quantity of fluid in its middle part:
the spermatic chord was pretty free, just at its exit from the
abdomen; but all between that point and the testicle was much
diseased.

Sqme of the gentlemen present expressed their apprehensions,
that the state of the process was such, that the operation would
most probably be unsuccessful, and therefore they were rather
inclined that the man should be discharged without any attempt
of that kind; but Mr. Freke thought otherwise, and performed it
immediately. The vessels of the diseased process were varicous
to a great degree, and very knotty and hard; the connecting mem-
brane was much thickened; the epididymis and testicle quite
confounded together; and in the body of the latter was a quantity
of bloody sanies, contained in two or three large cells.

The man got no rest after the operation, the vessels of the dartos
bled through all the dressings more than once, and in a few hours
he became very hot and restless, with a pulse quick and hard.

The next da} he bled again, not from the chord, but from the
whole dartos; his scrotum became much swelled, and loaded with
a lymphatic kind of tumefaction, but was very little inflamed; his
pulse was inconceivably rapid, but small; he complained of acute
pains in his back, a burning heat within it, an intolerable thirst,

164 A TREATISE ON THE HYDROCELE.

and an anxiety that was more terrible to bear than all the rest;
towards night (of the second day) his pulse faultered, he became
easy, and his extremities cold; and early on the third morning he
died.

CASE XLV1II.

A healthy man, under forty, came to me with a complaint in
one of his testicles, the epididymis of which was much enlarged
and hardened, while the body of the testis seemed to be in a natural
state.

His age, his general appearance, and the particular state of the
part, induced me to believe it to be venereal; but, upon asking
him a few questions, he asserted, that he had never received any
taint of that kind in his life. He said, that the first time he had
ever taken notice of this complaint, was about six weeks before,
after riding hard in the day, and dancing all night; that it was very
small at first, had increased gradually, and now began to be very
troublesome to him, either in riding or walking; and that not only
from its mere weight, but from frequent pain in it.

I am obliged to acknowledge, that I was at this time so preju-
diced by the general prevailing doctrine, that a true scirrhus or
cancer never began in the epididymis, that I tllought, eilher that
my patient was deceived himself, or had a mind to deceive me.

I therefore gave him a mercurial pill to take every night, con-
sisting of a small dose of calomel, with some kermes mineral, and
directed a small portion of ung. mercur. to be rubbed every evening
into the spermatic process.

By pursuing this method for about ten days, his mouth became
sore, and he was much displeased thereby. I gave him some
gentle cathartics, but his spitting kept at above a pint a day, for
more than a fortnight; at the end of which lime, the hardness, as
well as size and inequality of the epididymis and vas deferens were
manifestly increased; and his uneasiness in these parts was
greater.

The death of a near relation now called him into the country,
where he slaid about a month. At his return he sent for me. The

A TREATISE ON THE HYDROCELE. 165

disease was increased, but still confined to the epididymis; which
was now in that state, which I suppose constituted the caro adnata
of the ancients: it was hard, craggy, painful, and in size nearly
equal to the testicle itself; the darting pains were frequent; and
the uneasiness from its weight was constant and tiresome.

I was now satisfied of the true nature of the case, and let drop a
hint of the propriety of removing the part; but having a very
delicate and timorous man to deal with, I desired him to take the
opinions of some other gentlemen.

He saw Mr. Middleton and Mr. Nourse as surgeons, and a third
gentleman as a physician.

The two former advised immediate castration; the last seemed
to wish him to take the cicula, or the solanum, medicines then in
fashion. The thought of castration shocked him so much, that
he willingly embraced any hints concerning specifics.

He took the cicuta for more than two months, beginning with
a small dose, and increasing it gradually to very large ones. It
now and then made him a little sick and giddy; but the disease
increased under it so manifestly, that I was .apprehensive that we
were doing much worse than merely losing time. I signified my
suspicion, and pressed the operation; but he would not hear of it.
The solanum was now tried under the direction of the doctor;
but it disagreed so much, .even in the smallest quantity, that there
was no possibility'of persisting in it.

Upon this, as upon most occasions of this kind, every acquaint-
ance recommended either a specific or a quack; most of which
were tried, and I saw no more of my patient for above four months.
He then sent for me again. The whole testicle and spermatic
process, quite within the belly, were thoroughly diseased, hard,
and knotty; his pain was acute, and almost constant; and his
whole appearance truly pitiable.

He was much displeased that I, who had often pressed him (o
submit to the operation, would not now perform it; but it was too
late. In a few days after this visit, he applied to an operator, who
required a very considerable fee before-hand, and laid the whole
spermatic process open. A very terrible hemorrhage ensued, and
he died the next dnv in inexpressible agony.

166' A TREATISE ON THE HYDROCELE.

I visited a patient with Mr. Markland, whose first local com-
plaint was a hardened, enlarged, epididymis, and vas deferens;
and upon whom the whole power of mercury, and other supposed
deobstruent medicines, together with cataplasm, fomentation, &c.
were tried, during a long space of time, in absolute confinement,
but to no good purpose; the part became so large, so diseased, and
so painful, and the habit of the patient so much affected by it,
that extirpation was absolutely necessary. When the part was
removed, I examined it very carefully; and never saw a more true
and perfect scirrhus in my life. The epididymis was thrice the
size it ought to have been; its external surface was very unequal,
and very hard; and in the centre of it was a putrid slough, with
a small quantity of matter, jus; as it is found very often in the
middle of a scirrhous and cancerous testicle. The testicle was
hardly, if at all, altered from a natural state, except that the tuni-
ca vaginalis was generally adherent to the albuginea. Its internal
texture was soft, and bore very little mark of distemper.

I have, at this instant, a lad in St. Bartholomew's hospital, both
whose testicles are so truly diseased, that they must of necessity
be removed. I have seen him from the first of the attack. The
disease for several months occupied only the epididymis; and had
no connexion with, or dependence on, any venereal mischief. Every
thing that the art of surgery could do (or at least every thing
that I am acquainted with in it) has been tried, but without any
effect; and nothing but the operation can save him.

CASE XLIX.

Mr. William Sharp desired me to visit a patient with him.
The case was a scirrhous testicle. It was large, and very hard;
but smooih, equal, and no other way painful, than from its weight.
There was nothing in the testicle which forbade the operation; on
the contrary, it was in such state, as to promise very fair for suc-
cess; but the spermatic process, from the testis quite up to, and
apparently within, the opening in the abdominal tendon, was so
large and full, that it was impossible to feel the vessels. This ful-
ness, and increase of size, if it could be supposed to proceed from

A TREATISE ON THE HYDROCELE. IG1

a diseased state of these vessels and their membranes, was such a
bar to castration, that nobody could possibly think of it in such
circumstances; but, on the other hand, if it could be supposed to
be owing to an extravasated fluid, the withdrawing such fluid
might make a very material alteration in the state of all the parts.
Mr. Sharp said, that he had seen this patient some months before,
and had let out (as he thought from the tunica vaginalis) a quan-
tity of water; and that he then found the testicle a great deal too
large; and was very sure that he then distinctly felt the spermatic
vessels. The tumid process, though large, full, and tight, yet was
smooth and equal throughout; and I thought, that I could very
plainly feel a fluctuation through the whole of it; that is, from the
opening in the oblique muscle, to the upper part of the testicle.
The patient was young and healthy, the weight and size of the tes-
ticle very troubelesome; and nothing but this state of the process
in the case, to make it necessary to defer the operation a moment.
A puncture was made with a large lancet into the tumor just above
the testicle; near a pint of clear yellow serum was discharged;
the swelling subsided; the spermatic vessels, which were in a
sound, natural state, became easily distinguishable; the operation
was immediately performed, and proved successful.

CASE L.

A poor sailor, who had been discharged from one of the navy
hospitals, applied to St. Bartholomew's.

He had a scirrhous testicle, which was not large but was as hard
as marble; very craggy and unequal, and attended with frequent
acute pain; the process also was so large, that, upon such examination
as I had then time to make, I told the man, that I did not conceive
that he could receive any benefit, even from the operation; but
one of the governors, prevailed on by the man's solicitation, desir-
ed that he might be admitted.

The first time we were all met together, I produced this man
for the general opinion; which was, that if the increased size of
the spermatic process was the effect of a diseased state of the parts
composing it, the operation was improper, as it would only hasten

168 A TREATISE ON THE HYDROCELE.

the man's death, and that in a very painful manner; but if it could
be thought to be owing (as in the preceding case) to an extravasa-
tion of fluid in the common membrane, it was certainly worth while
to try what the discharge of that fluid might produce.

The whole was related to the man; he was informed of our
doubts, of what we intended to do, and of the probability that it
might be of no service to him; a puncture was made in that part
of the process where the fluid was most palpable; a large quantity
of lymph was discharged, the tumor subsided, the spermatic ves-
sels became very distinguishable; (he operation of castration was
immediately performed, and the man went out from the hospital
well.

CASE LI.

A poor man was taken into St. Bartholomew's hospital, for a
complication of complaints; but particularly for a frequent and
acute pain in his back and belly.

When he had been there a day or two, he told the nurse that
he had a complaint in his scrotum; and the next day I was desired
to look at him.

He had a diseased testicle of the scirrhous kind, which was not
very large, but was hard and unequal; the spermatic process was
not in a natural state, nor very much diseased; and he had a large
and very troublesome omental hernia. The man had also a very
morbid aspect; had his rest frequently disturbed by pain, and was
near to fifty years old.

He was very solicitous to have something done for him, and
willing to submit to any thing for that purpose; but his case was
such, as to render it not an easy matter to determine what to do.

His rupture was large, and very troublesome; it was merely
omental, and could not be kept up a moment, while he was in an
erect posture, without a truss; a truss he could not wear to any
good purpose, without the pad of it pressing on the spermatic
chord, and aggravating a greater evil than his rupture; viz. his
scirrhous testicle. The weight of his rupture, added to that of

A TREATISE ON THE HYDROCELE. 169

his scirrhous, rendered it impossible for him to get his bread by
labour.

The only method whereby, he could be made capable of wear-
ing a proper bandage for keeping up his rupture, or even of sus-
pending it with ease, was, by submitting to have the scirrhous
testicle removed by castration; and then, his rupture being return-
ed, he might be enabled to wear a truss. But to this there were
some objections. In the first place, the hernial sac came so low,
that the process could not be tied, or cut off, without the sac hav-
ing been first either laid open, or dissected off from it. In the
next place, I did not like the state of the spermatic process, which
was both too large and too hard; and in the third place, I thought
the general circumstances of. his morbid appearance, and bad
state of health, were great objections to operations of such conse-
quence, as either the laying open, or dissecting of the hernial sac
from the spermatic process, or castration.

All this was related to the man in the fairest manner possible;
and he desired to have such, or any operation performed, which
I should think right.

Having been confined to his bed for more than a week previous
to the operation, the omentum had hardly ever been down during
that time, and was now perfectly up. This, though it might
prove a circumstance in the man's favour, was none in mine as
an operator; for the hernial sac being empty and flaccid, gave me
thereby more trouble. The hernia was of the congenial kind;
and, consequently, when I had divided the sac to the bottom, the
state of the spermatic chord and testicle was manifest; and I had
only to pass my needle and ligature round the upper part of the
former, without paying any more or particular regard to the her-
nial sac. Upon a nearer view of the state of the process, I liked
it still less than I had done before; but there was nothing now
could be done, but to go through with the operation, and to take
the chance of it. I did so; the man bore it well, and was better
for the first two or three days, than I could have expected. After
the first week was past, I was daily surprised at the good state of
my patient. He was easy, free from pain or fever, slept well,
look nourishment: and if was impossible for any «ore to be or to
look better.

vol. ir. T

170 A TREATISE ON THE HYDROCELE.

At the end of three weeks, when he was to all appearance well,
and his sore almost healed, he was suddenly seized with pain all
over him, and died on the second or third day from this attack.

I had him opened. The portion of omentum, which had form-
ed the hernia, had an attachment to the peritoneum, just within
the mouth of the hernial sac; which, I suppose, was the reason
why it could not be kept up while he was erect. The lymphatic
glands about the lumbral vertebrae were all diseased; the liver
was scirrhous throughout, and had a large collection of matter in
its lower part.

AN ACCOUNT

OF THE

METHOD OF OBTAINING

A PERFECT OR RADICAL CURE

OF

inmB IH¥IDIB®©ISIL33s>

BY MEANS OF A SETON.

CURE OF HYDROCELE

BY A SE TON.

An HHrtiOcELE is so irksome a disease (o the indigent and la-
borious, furnishes even the easy and opulent with such disagree-
able ideas and apprehensions, and is to all who are afflicted with
it so troublesome and inconvenient, that every rational attempt
toward relieving mankind from such an evil, will, I make no
doubt, be favourably received.

It is now some years since I first began to make particular in-
quiry into the nature of this and some other diseases of the testi-
cle, and the usual methods of treating them: an inquiry, which
they appeared to me for many reasons, both to deserve and require.
The result I communicated to the public, under the title of " A
" Treatise on the Hydrocele, or Watery Rupture, and other Dis-
" eases of the Testicle, its Coats, and Vessels;" in which I en-
deavoured to be as precise and as explicit as I could.

One part of this tract contains an examination of the various
means, which, at different times, have eilher accidentally produc-
ed a radical cure, or have been professedly proposed and practised
for such purpose.

Among other means used to obtain this end, I mentioned the
seton; and spake of it as that which for many reasons, appeared
to me to be preferable to all others; as a method which I had for
some time practised with great success; and as that which, if no-
thing should occur to induce me to change my opinion, I should
continue to m,ake use of.

Since that time I have had frequent opportunities of repeating
the experiment; and it has so constantly and uniformly answered
my expectation, that my opinion conceVning it is determined; and
I am convinced, that it is the most successfully efficacious of any.

This might be urged, and would perhaps be admitted, as a good

171 RADICAL CURE OP THE HYDROCELE

reason for laying my though is on the subject again before the
pub!i( ; but I have others also to plead in vindication of the few
following pages.

In (he first place, I think that I have considerably and materially
improved the operation and process; and have rendered it less
painful and more certain.

In the second, I rind, that what I said of it in the general trea-
tise, has not been so clearly and perfectly understood as I could
have wished, and in consequence either of brevity and obscurity
on my part, or misunderstanding on the part of some of my
readers, my true meaning has not been received; and I have
been subjected to the frequent interruption of troublesome corre-
spondences on the subject.

And, in the third place, I might add, that some few gentlemen
of consequence, who have by this means been cured, have re-
quested this publication.

A minute account of the nature and circumstances of the dis-
ease, would be a mere repetition of what I have already said at
large in the book referred to; would be therefore unnecessary, and
beside my present purpose: a short and cursory one may perhaps
throw just as much light on the subject, as may serve to render
the description of the operation, and the treatment after it, more
easily intelligible.

The common bag in which both the testicles are included, is
called the scrotum, and consists of epidermis, skin, and that loose
cellular membrane, which is here called the dartos; to which
might perhaps be added the expanded fibres of the cremaster
muscle on each side. The proper coats of the testicle are, the tu-
nica albuginea, and the tunica vaginalis. The former of these
immediately invests the vascular compages of the testis, and is
that coat with which it is covered while within the cavity of the
abdomen, before birth. The latter is formed on the outside of the
said cavity, is a process of the peritoneum, and is placed ready
for the reception of the testicle when it shall be thrust forth
through the groin into the scrotum. Between the vascular struc-
ture of the testicle, and the tunica albuginea, there is no vacuity;
but the external surface of the gland is in every part firmly adherent
to, and connected with, the internal one of the investing coat: the tu-

BY MEANS OF A SETON. 175*

nica vaginalis forms a hollow cavity, or bag, which loosely and
unconnectedly envelops the testicle, covered by its albuginea.

When I say loosely and unconuectedly, I would wish to be un-
derstood aright. I do not mean that the testicle hangs in the
middle of the tunica vaginalis (like a clapper within a bell,) and
has no connexion with it — I mean that all the superior, anterior,
and lateral parts of the tunica vaginalis are loose from, and un-
connected with, the testicle, which is at the same timu firmly
united to its posterior part, in such manner, that if the cavity of
the tunica vaginalis was to be distended with wind, such wind
would occupy or fdl all the loose and unconnected part, and pro-
duce a tumefaction not unlike to a hydrocele, while the testicle
would be found firmly and immoveably attached to the hinder
part of the said cavity so distended.

To prevent the accretion of these coats in those parts where
they ought to be unconnected, and perhaps for some oilier pur-
poses, the cavity of the tunica vaginalis is furnished with a fine
lymph constantly exsuding into it; which lymph is as constantly
absorbed by proper vessels; so that, in a healthy and natural
state there never is any more of this fluid within the bag at a
time, than may just serve (beside what other purpose it may be
intended for) to keep the two membranes from coming into imme-
diate dry contact and cohesion with each other. This small
quantity is sufficient to preserve the proper and natural cavity of
the tunic; but never occasions any degree of intumescence, or any
unnatural or diseased appearance of the part.

A deficiency, or total failure of the secretion of this fluid, will
be followed by a partial or toial coalescence of the two coals with
each other; and consequently a total or partial abolition of the
cavity. A superabundance^ or a secretion of more than the ab-
sorbent vessels can take up, must, on the other hand, enlarge and
distend the said cavity, by carrying all the loose unconnected part
of the bag further and further from the testicle, in proportion to
the quantity accumulated. The former, 1 do know to be some-
times, and I verily believe most frequently is, the consequence of
a severe hernia humoralis, as well as of other inflammations of the
testicle. The latter, among other diseases, produces the hydro -
drocele or watery rupture.

176 RADICAL CUKE OF THE HYDROCELE.

This being the case, (hat is, the intumescence of the scrotal bog
being caused by the gradual accumulation of a fluid, which ought
to have been absorbed, it is almost always produced gradually; and
therefore has, in most instances, made some progress before it is
taken notice of; especially by careless and inattentive people. For
the same reason it will be found, that as it depends upon the cir-
cumstances of secretion and 'absorption, it will, in different people,
make quicker or slower progress, according as the deposition
shall happen to be quicker or slower, and the absorbent faculty
only more or less impaired, or totally obstructed. As this disease
is confined to the cavity of the tunica vaginalis testis, and as this
bag has no communication with the cavity of the belly, the tume-
faction can never be lessened by any attempt toward reducing or
returning it into the abdomen. For the same reason, it never is,
nor can be liable to any alteration of size, or temporary distention,
from tbe efforts or actions of coughing, sneezing, expulsion of
faeces, &,c. For ihe same reason, (I mean the confinement of the
fluid within the cavity of the tunica vaginalis,) the intumescence,
when early attended to, will always be found in the lower part,
and docs not rise above the upper part of the testicle, until the
disease has" made some progress, and the quantity is become con-
siderable; therefore the spermatic process will always, in the early
stage of this distemper, be capable of being felt perfectly and dis-
tinctly; although when the tumor has arrived to any considerable
degree of size, the fluid docs so conceal the testicle, as to render it
not a very easy matter to find it The three last circumstances,
well attended to, will always serve to distinguish the hydrocele
from the intestinal hernia or common rupture, at least in the be-
ginning. To these might be added, several other characterislical
marks of this distemper, sueii as: Tbtt being neither accompanied
by, nor occasioning any inflammation or irritation, it never gives
pain, unless it be very ruddy handled, or be permitted to attain
such size as to be troublesome from its weight, or to be subject to
excoriation from its magnitude; which may serve to distinguish it
from the hernia humoralis, an inflammatory and often a very pain-
ful disorder. That if the fluid be thin and limpid, and the va-
ginal coat and membranes of the scrotum not thick, the tumor is
often in some degree transparent; that is, the light of a candle or

BY MEANS OP A SETON. 177

lamp may be seen through it. That constipation of the belly does
not render it at all more tense, or produce any uneasiness in it
while it lasts; neither does the removal of such obstruction or con-
stipation at all lessen its volume, or make any alteration in it,
either to the eye or to the finger. To all which ought always to
be added, the fluctuation of the fluid.

The size and figure of the tumor, caused by this disease, are
liable to considerable variety, dependent upon the quantity and
consistence of the fluid accumulated; the time such accumulation
may have taken up; the thickness or thinness of the vaginal bag
and membranes of the scrotum; and the equal or unequal manner
in which these parts may have given way to the distention. Hence
the tumor will be larger or smaller, round, flattish, pyriform, or
globular; will be firm, tense, and resistent, or lax, soft, and easily
compressible; smooth and regular in its surface, making one uni-
form figure, or divided by a kind of depression or stricture, which
will make it appear as if the water was in two distinct sacculi or
bags; it will also be more or less tense, as well as regular in its
surface, as the contractile power of the scrotum, by means of the
cremaster muscles, shall be more or less.

The qualities of consistence and colour in the contained fluid is
also various: it is thin, aqueous, ropy, viscid, limpid, citrine,
greeuish, brown, bloody, clear, or turbid; from each of which
some small differences in the aspect, feel, weight, transparency,
or obscurity of the tumor will arise; but are of no consequence
with regard to any method of treatment, palliative or radical.

The methods of cure of a hydrocele are said to be two, one
called the palliative, the other the radical; the latter of which
alone deserves the name of cure.

The former consists merely in letting out the water occasionally,
and is so simple and so trifling an operation, that I shall say no-
thing more of it, than that I think a small trocar a much prefer-
able instrument for this purpose, on all accounts, to the lancet, or
any other.

The radical cures, as they are called, may be collected from
the writings of several of our predecessors. The general means
they made use of were cautery, caustic, ligature, and tent. For
the particulars relative to each of these, I must beg leave to refer

vol. II. z

178 RADICAL CUKE OP THE HYDROCELE

my reader to the writers themselves, a minute detail of them not
being consistent with the plan of these few sheets. But without
entering into such disquisition, I believe I may venture to say, that
whoever will give himself this trouble, will find, that ail the means
which were either professedly used to obtain a radical cure, or
which ultimately and accidentally produced such event, were put
in practice for three general reasons, or under the influence of
three general opinions; the first of which was, that the fluid found
in the sac of a hydrocele was always originally formed in the
cavity of the belly, and descended from thence into the scrotum;
the second, that it was a disease of the habit, as well as of the
particular.part, that is, that it was general, as well as local; the
third, that the collection of liquor found in it was either the neces-
sary cause, or the consequence of a diseased state of the testis.

From these flow the applications of cautery and caustics to the
groin, and of ligatures on the spermatic process. From these are
derived all the cautions to undertake the cure guardedly, to con-
duct it slowly, and to attend rigidly to the patient's general state
by cathartics, alteratives, specifics, issues, &c. &c. &c; and to
these we owe the experiments made to induce suppuration from
the parts affected.

Not being acquainted with the anatomical structure and dispo-
sition of the parts concerned in the disease, they had very terrible
as well as very erroneous notions concerning it. They supposed
that the fluid contained in the cyst was thrown off from the habit
as a kind of crisis; that the general constitution of the patient was,
by such deposition, much relieved; that it prevented many other
and those worse disorders; and, either that a morbid state of the
testicle and epididymis concurred in producing the fluid, or that
the same parts necessarily became diseased from lying in it.
They therefore concluded, that although a radical or perfect cure
might be obtained by certain means, or that certain means having
been found now and then to have produced such event, they might
with probability be expected to answer such purpose, yet the
attempt ought never to be made without a strict attention to the
general evils which might ensue, as well as to the particular ones
proceeding from the supposed morbid state of the parts.

BY MEANS OF A SETON. 179

Inquiry and experiment have taught us better; have given us
truer notions of the nature of the complaint; have induced us to-
tally to lay aside many of the means used by our forefathers; and
although we do still in some sort continue some of them, yet it is
upon different principles, and with very different views.

The noxious quality of the fluid; the diseased state of the parts
whence it proceeds, or wherein it is deposited; the critical, or
depuratory nature of the deposition; the necessity of drawing off
the water partially, and at short intervals; and the fear of curing
it locally, lest the general habit should suffer, are all now known
to be groundless apprehensions; and it being also known, that the
collection of fluid is originally made in the tunica vaginalis only,
and that it does not descend from the belly, all attempts towards
preventing such descent are become equally absurd.

The testicle, although frequently somewhat enlarged in its di-
mensions, and relaxed in its texture^ is known to be sound, to be
otherwise unaffected and unaltered, and to be fit for, and capable
of performing the functions it was designed to execute; the fluid is
acknowledged to be innoxious in its nature, neither proceeding
from parts in a diseased state, nor causing any disease in the parts
in which it is deposited, and with which it is in contact; but being
accumulated in consequence of constant secretion, and deficient
or non-executed absorption, the intention of every rational prac-
titioner, when he aims at a radical cure, is, to abolish the cavity
of the tunica vaginalis, and thereby to prevent any future collec-
tion.

Whatever means can accomplish this end with the least fatigue,
pain, or hazard, are certainly the best.

Of the incision, I shall in this place say nothing, except that it
lies under so many restraints from a variety of circumstances, is so
improper for the majority of persons afflicted with the disease, and
requires such nice attention, and such judicious management, that
it never can be recommended as fit for general practice.

The caustic, upon the rational principle of which I am now
speaking, viz. that of abolishing the cavity of the tunica vaginalis,
has been practised by many, and that with such success, as to
induce some to think it the best and most eligible method. Among

ISO RADICAL CURE OF THE HYDROCELE

these is Mr. Else, who has lately published his opinion on the
subject.

The introduction of suppurative medicines, by means of a tent,
was practised by some of even our remote predecessors; and, as
they tell us, with success, even in complicated cases; that is, in
cases where a diseased state of the testicle has been added to the
hydrocele. But whoever will attentively consider their accounts
of this matter, will see, that this method, whatever might be its
accidental consequence, was not intended for the purpose which I
am now speaking of.

Perhaps there is no part of surgery which was less understood
by our ancestors, or concerning which they expressed themselves
with so little precision, as the subject of diseases of the testicle:
they have multiplied and confounded them in such manner, and
speak of them in such a jargon of unintelligible terms, that it is
next to impossible to understand often what they really mean.

For a particular elucidation of this subject, the chirurgic world
are much obliged to the late professor Munro of Edinburgh, and
Mr. Samuel Sharp, late of Guy's Hospital, now of Bath.

The accounts which many of the best among the writers in
surgery, even quite into our own time, have given of the diseases
of these parts under the terms sarcocele, fungus attached to the
spermatic vessels, fungus arising from the testis, hydrocele, and
hydro-sarcocele, are error itself; and the operations which they
describe and recommend are many of them coarse, and either
impracticable or very unfit for practice. Blit, however, from these
accounts, strange and irrational as they are, we may collect that
they conceived the diseases which they call the hydro-sarcocele,
and the caro adnata ad vasa spermatica, to be (in contra-distinc-
tion from the sarcocele, and the fungus springing from the testicle)
curable diseases, the one by extirpation of the fungus, the other by
suppuration.

No precise definition of what they have thought proper to call
the hydro-sarcocele has been given by them, and therefore we have
no better method of forming a judgment concerning it, than by
considering the event and success of their method of treating what
they have so called, with what we know concerning the structure
of the testicle, its disorders, the means which we now find to be

BT MEANS OF A SETON. 181

successful in them, and the disappointments and disagreeable cir-
cumstances which sometimes occur in them.

Fabritius ab Aquapendente has been particular on what he calls
the hydro-sarcocele, and has given an account of his method of
curing it; but whoever is acquainted with diseases of the testicle,
and will compare with such knowledge what Fabritius has said
concerning his method and its success,* will, I am inclined to
believe, think on this subject as I do; that the disease which he
gave this hard complex name to, is nothing more than true, simple
hydrocele, in which the testis is somewhat enlarged beyond its
natural size, and perhaps somewhat relaxed in its texture, in con-
sequence of such enlargement; but still sound, and free from
disease; still fit for, and capable of, executing its office.

That by his method he obtained a radical cure I make no doubt:
his ' turunda digestivo et pus movente medicamento imbuta, 1
would most probably occasion a sloughing of the tunica vaginalis,
and consequently an abolition of the bag or cavity. But whoever
knows any thing of these matters, must know, that a testicle really
and. truly diseased would not bear such treatment; and therefore,
that his success was owing to the state of the testicle not being what
he supposed it to be, and what the term he makes use of implies.

The method of Fabritius was within a few years past adopted
and practised by Ruysch. b

The means and conduct were nearly the same, and I have no
doubt that the success was equal. But the same objection still

* " Si carnosa simul et aquosa sit hernia, ego talem adhibec curam. Seco
" cutem et incisionem facio et exiguam, et in loco potius ultiori quam in
" fundo, inde turunda imposita, cum digestivo et pus movente medicamento
" procedo, neque unquam totum pus extraho, sed perpetuo bonam partem
" intus relinquo, quod sensim carnem corrodat et ita sanat."

Fab. ab A«iuafeni)ente.

b " Sanara quidem valet id mali pertuso scroto ope instrumenti trocher*
" dicti, vel Ianceola phlebotomica, ut aqua vulnere exeat, sed cito plerumquc
" recrudescit ?nalvm.

" Si autem curationem aggrederis aperiendo scrotum a parte superiori, ad

" latus, tumque vulnus turunda oblonga, unguento rosaceo mercurio praeci-

" pitato rubro inuncto oppleveris, donee Ienis inflammatio, eique succedens

" suppuratio parva, membranules stillantes putrescent, tuncque eas tenaculcv,

" eduxeris," 8cc.

Ftysch

182 RADICAL CURE OF THE HYDROCELE

remained; which was, that not only a suppuration was brought on,
but the whole tunica vaginalis was so irritated and inflamed, that
it necessarily became sloughy, and was entirely destroyed; an
objection which had been made to the method by caustic; and
which, I must acknowledge, is, in my opinion, an objection to it
still.

The late professor Monro, whose observations on the diseases
of the testicle are very pertinent and very ingenious, seemed to
think that it was by no means impracticable, by means of a slight
degree of irritation, to excite such an inflammation both in the
tunica vaginalis and albuginea, as might occasion a coalescence
of them with each other, and thereby answer the end of abolish-
ing the cavity, without destroying any part of either tunic.

I made the experiment proposed by him, and found it some-
times successful; never hazardous or prejudicial, but by no means
certainly efficacious, or to be depended upon. The cannula, by
its hardness and resistance, was a very unpleasant guest within
the vaginal coat; and from its inflexibility, upon any unguarded
motion of the patient, injured the testicle, and gave very acuta
pain; and the tent and bougie, which I occasionally substituted
in its place, although they did not give so much pain, were liable
to a considerable degree of uncertainty.

Uncertainty and hazard are certainly very different things, and
the latter much preferable to the former: not to have injured a
man by an experiment, affords some degree of consolation under
a disappointment; but yet, when it is considered, that an opera-
tion and process of this kind are submitted to from choice, and not
from necessity, if it fails of success, although no real harm be done
cither to the part, or to the constitution of the patient, both the loss
of time and the confinement will become doubly irksome, as they
will be found not only not to have answered the end proposed,
but not to have brought the patient at all nearer to a cure than he
was before the attempts. The reflection is unpleasant to both
parties.

Being, from the effects both of the cannula and tent, satisfied
that there was no kind of hazard in the introduction of a foreign
body into the cavity of the tunica vaginalis, nor from its remain-

BIT MEANS OF A SETON. IS.J

ing there; and having many opportunities of meeting with this
disease in St. Bartholomew's, 1 determined to try what a seton
would do toward raising such a degree of inflammation as might
occasion a coalition of the two membranes, and effect the purpose
proposed by professor Monro. The success fully answered my
expectation. ,

In my general treatise on the diseases of the testicle, I mention-
ed and recommended it; but as I could not be certain what a
greater length of time might produce to make me change my opi-
nion, I mentioned it with some degree of caution.

Since that time I have embraced every opportunity, both in the
hospital and out, of practising it, and that under some improve-
ments; and as I can now speak positively to its success, I thought'
it right to give it to the public, who are always intituled to every
benefit arising from the labours of every man whom they have ho-
noured with any degree of confidence; and this as well on a prin-
ciple of humanity as of gratitude.

What I have said of it in the general treatise is in the follow-
ing words, " The point to be aimed at is, to excite such a
u degree of inflammation, both in the tunica vaginalis and tunica
" albuginea, as shall occasion a general and perfect cohesion
"between them; and this, if possible, without the production of
" slough or abscess; without the hazard of gangrene; and without
" that degree of symptomatic fever which how and then attend

c His words are, "Considering' how readily contiguous inflamed parts
" grow together, and how many instances there are of people having a radi-
" cat cure made of this hydrocele by inflammations coming on the part, it
" would seem no unreasonable practice to endeavour a concretion of the two
" coats of the testicle when they are brought contiguous, after letting out
'• the water through the cannula of a trocar, by artfully raising a sufficient
" degree of inflammation.

" This to be sure must be done cautiously, and so that the surgeon can
" reasonably expect to be master of the inflammation; and therefore the ap-
" plication of all irritating medicines, the operation of which he could not
" immediately stop, or any single mechanical effort, the effect of which he
" could not be sure of, are not to be employed.

" Suppose the cannula of the trocar was to be left, by the extremity of it
" rubbing against tlic testicle, an inflammation might be artfully raised, the
.*' cause of which might he taken away as soon as the surgeon thought fit."

MEDiciX Ebsats.

184 RADICAL CURE OF THE HYDROCELE

" both the caustic and the incision; and which, when they do hap-
" pen, are so alarming both to patient and surgeon.

" These ends I have frequently obtained by the use of a seton.

" It is a method of cure mentioned by Aquapendens from Guido,
" and others before him, though their process was somewhat dif-
" ferent frem mine. I have several times tried it on subjects of very
" different ages, some of them more than fifty years old. It re-
" quires confinement to bed only for a few days, after which the
" patient may lie upon a couch to the end of the attendance,
" which is generally finished in about three weeks or a month at
" furthest, and during all that time no other process or regi-
a men is necessary, than what an inflammation of the same part
'" from any other cause, (for example a hernia humoralis) would
" require.

"The manner of performing it is as follows: Choose a time
" when the vaginal coat is moderately distended, and having
" pierced it with a trocar of tolerable size, draw off the water;
" when that is done, introduce into the cannula a probe armed
" with a seton consisting of ten or twelve strings of candle-wick
" cotton; pass the probe as high to the upper part of the vaginal
" coat as you can, and on the end of that probe make an incision
" of such size as to enable you to pull it out easily, together with
" a part of its annexed seton; then cut off the probe, and tie the
" cotton very loosely, covering the orifices with pledgets. By the
" next day the seton will be found to have contracted such an
" adhesion to the tunica albuginea as would cause a great deal of
" pain to detach; but this it is perfectly unnecessary to do, and it
" should be suffered to remain without molestation. In about
" forty-eight hours the scrotum and testicle begin to swell and
" inflame; the patient should then lose some blood, and have a
c: stool or two, and the whole tumefied part should be wrapped
" in" a soft poultice, and suspended in a bag -truss. The disease
" from this time bears the appearance of a large hernia humora-
" lis, and must be treated in the same manner, by fomentation,
" cataplasm, &c.

" The adhesion of the seton to the albuginea generally continues
" firm, and I never meddle with, or move it, till it becomes perfectly

BY MEANS OP A SETON. 185

" loose, which it seldom does for the first fortnight, or until the
" inflammation is going, and the tumor subsiding. By the time
" the seton becomes loose, the coalition of parts is universally
" and firmly accomplished: I then withdraw it, and heal the ori-
" fices with a superficial pledget, &c."

This method was, as 1 said, in general very successful; but re-
peated trials furnished me with objections to some parts of it,
and induced me to think that such parts might be amended.

I found that cutting upon the end of the probe was troublesome,
both from its smallness and from its flexibility, and also that it
was sometimes difficult to keep it steady for the same reasons,
and that it always required the assistance of another person's
hand besides that of the operator — a circumstance one would al-
ways wish to avoid, when possible. I found also, sometimes, that
the seton of a candle-wick cotton did not pass so easily as I could
wish, and by rubbing the tunica albugineatoo rudely, gave more
pain than I liked. The seton, as made of cotton, adhered, in
some instances, too long and too firmly. From the intimate con-
nexion of the parts of the wet cotton with each other, it could
never be brought away but entire; which in some cases occasion-
ed an unnecessary waste of time$ and, what was still worse, in
two instances it adhered so firmly, that I was obliged to make a
small incision to get it away at all.

All these inconveniences and objections I have now obviated
and removed.

The instruments I now make use of are in the annexed plate,
and are — -

A trocar, the diameter of whose cannula is very nearly, but not
quite, one fourth of an inch; another cannula, which Icalltheseton-
cannula, which is made of silver, and is of such diameter as just
easily to pass through the cannula of the trocar, its length five
inches; and a probe of six inches one half long, having at one ex-
tremity a fine steel trocar-point, and at the other an eye which
carries the seton; which seton consists of just so much strong,
coarse, white sewing-silk as will without difficulty pass through
the latter cannula, but at the same time will fill it.

With the trocar, the inferior and anterior part of the tumor is

to be pierced, as in common palliative tapping. As soon as the
vol. n. a a

186 RADICAL CURE OF THE HYDROCELE

water is discharged, and the perforator withdrawn, the seton-can-
nuia is to be passed through that of the trocar, until it reaches the
upper part of the tunica vaginalis, and is to be felt in the very up-
per partofthe scrotum. This done, the probe, armed with its seton,
is to be conveyed through the latter cannula, the vaginal coat and
integuments to be pierced by its point, and the seton to be drawn
through the cannula, until a sufficient quantity is brought out by
the upper orifice. The two cannulas are then to be withdrawn,
and the operation is finished. It is executed in two or three
seconds of time, and with little more pain than is fell in common
tapping.

By this method, every advantage which attended the former
operation is obtained, and every inconvenience which it was li-
able to is obviated and provided against.

The seton-cannula, by iis firmness, bears tight against the place
where (he seton should be brought out; the trocar-point of the
probe is kepi from deviating by its confinement, and its point
pierces through the skin immediately and exactly in the place in-
tended; while the seton, by passing through the cannula, is pre-
vented from rubbing rudely over the testicle.

As soon as the operation is finished, I put the patient into bed,
and immediately give him twenty or twenty-five drops of tinctura
thebaica, which I repeat or not, pro re nata.

About the third day the testicle and scrotum begin to inflame and
swell, and to put on the appearance of a hernia humoralis, or the
swelled testicle which now and then attends a gonorrhoea, and re-
quires the si.me, and no other kind of treatment; that is, fomen-
tation, poultice, a suspensory bag, a cool, temperate regimen, and
ah open belly.

By these means the inflammation is soon and easily appeased.
As soon as this end is accomplished, I permit the patient to get
oui of bed, and lie on a couch, or sit in a great chair, with his legs
up; and I generally give the cortex, in some form or other, twice
or thrice a day.

The soreness and tumefaction now diminish apace; and as soon
as the parts are quite easy, which is generally about the tenth or
twelfth, day, I begin to withdraw the seton, taking out four, five,
six, or seven threads of it at each dressing] which dressing con-

BY MEANS OF A SETON. 187

sists of nothing more than a superficial pledget upon each of the
orifices while they continue open, and a discutient cerate (such as
the ceratum saturnin.) to cover the scrotum.

The discharge of matter from the orifices is small and trifling,
no more than might be expected; the tunica vaginalis does not be-
come sloughy, but is preserved entire; and the cure is ac-
complished merely by the coalescence or cohesion of the tunica va-
ginalis with the tunica albuginea — an event, which, from what
has fallen within my observation, I am inclined to believe is
most frequently the consequence of a severe hernia humoralis.

In this circumstance, viz. the accomplishment of the cure, by ad-
hesion of the two coats together, without any destruction of parts,
consists the material difference between the method of cure by
seton, and that by caustic.

All the practitioners who make use of the latter allow, that it
produces a slough of the whole tunica vaginalis; that it destroys
the whole bag or cyst; and that it is used with intention so to do.

In the cure by seton no slough is produced, (at least I have ne-
ver seen one,) nor is the vaginal coat destroyed in any part of it;
a firm cohesion is made between the two membranes, occasioned
by the inflammation; and the cure is effected solely thereby.

I shall always most gladly embrace any opportunity to improve
so noble and so really useful an art as surgery; but, at the same
time, should be very sorry to have it supposed, that any partiality
to my own opinion would make me misrepresent, or deviate from
truth.

Since this pamphlet first appeared, Mr. Else has published a
second edition of his account of the cure by caustic.

In this he has recited two attempts by the seton, which were
under the conduct of Mr. Martin, in St. Thomas's hospital.

I make no doubt that the circumstances were as Mr. Else has
related them; but I must take the liberty of saying, that although
I have practised the method of cure by seton on a very consider-
able number of people, both in the hospital of St. Bartholomew,
and out of it, of all ages and in all circumstances, I have never
yet met with that trouble, or those disagreeable symptoms, which
Mr. Else has related as happening to Mr. Martin's two patients:

188 RADICAL CURE OF THE HYDROCELE, &C.

on the contrary, I am, from very frequently repeated experience,
convinced, that the cure by the seton is by much the least ha-
zardous, painful, or fatiguing, as well as the most expeditious and
certain of any yet proposed.* 1

d Although I am as much a friend to simplicity in chirurgic operations as
any man can be, and think that whatever can be well done by means of one
instrument, is most frequently better done than by means of several, yet, in
this instance, I cannot help thinking otherwise.

The intent of the seton-cannula is to defend the tunica albuginea testis
from the rude passage of the silk over it. From the paui and other disagree-
able circumstances which I have seen attend the omission of it, 1 must again
recommend its use, though'it does add to the instrumental apparatus. From
frequent and repeated experience, 1 must also advise the using a skein of
white silk instead of ribband or tape.

Whatever is used will necessarily contract some degree of adhesion to the
testicle during its inflamed state ; and this adhesion will unavoidably create
some little trouble and uneasiness whenever the seton is withdrawn ; but this
pain and trouble will necessarily be least when the seton is composed of such
materials as are capable of being taken away at different times, instead of all
at once.

When a seton of any kind is used for the purpose of making, or of continu-
ing, a drain of matter, it is right to move it daily, and frequently to shift it ;
but in this case, as the intention is different, so should our conduct be. The
intention is merely, by the residence of the seton, to excite such a slight de-
gree of inflammation as shall occasion an adhesion of the tunica albuginea tes-
tis to the tunica vaginalis, and not a suppuration : the moving it daily, or even
at all, until the proper time of taking it quite away, can do no good, and
must, by exciting unnecessary pain, do harm.

I therefore must repeat my advice, to let it remain unmoved for a week or
ten days, at the end of which time it will have accomplished its end, and
then had better be removed than not.

Suppuration is not only not intended, but should, as much as it may be in
our power, be guarded against.

RADICAL CURE

^phis snriDi&®@]siLa

BY

MEANS OF AN INJECTION.

BY THE EDITOR.

CURE OF HYDROCELE

BY INJECTION.

The inconveniences attending the usual methods of treating
the hydrocele are well known to those who are engaged in the
practice of surgery. The disease itself is attended with little pain
and no danger: many of the remedies now in use for it arc pro-
ductive of considerable pain, and are not totally destitute of
hazard.

The proper object of all operations for the radical cure of the
hydrocele, is to produce such an adhesion of the distended vaginal
coat of the testis with the gland, or such a consolidation of the conti-
guous parts, as shall annihilate the cavity in which the water con-
stituting this disease is contained. We know that this effect may-
be produced by a certain degree of inflammation, and are unac-
quainted with any other process, either natural or artificial, by
which it can be brought about. Before the method by the seton
was recommended by our author, the necessary inflammation was
excited by dividing the scrotum and the vaginal coat, or by de-
stroying a part of them by the knife or caustic.

Mr. Pott took no small pains to mitigate the severity of this
operation, and to raise inflammation in a more simple manner, by
the introduction of a foreign body, without destruction of parts.
With this view he preferred the seton. This he soon discovered
to be productive of more inflammation than was necessary; and,
after a series of trials, he suggested many very ingenious directions
for performing and conducting this operation, in such a manner as
to produce the least possible irritation. We must allow that he
carried the process he recommends to a great degree of perfection;
and if the operation be performed without deviating from the direc-
tions he has laid down, I am convinced it will be found preferable

192 RADICAL CURE OF THE HYDROCELE

to any of the methods which have been usually practised in this
country; yet it must be observed, that even this remedy goes
beyond the proper intention, as the seton not only excites adhesive
inflammation, but is necessarily attended with some degree of sup-
puration, at least in the track of it, before it can be removed: add
to this, an objection of much more practical consequence, that even
in its present state the inflammation produced by the seton some-
times runs much higher than is intended, and demands the atten-
tive administration of antiphlogistic remedies.

The late Mr Else's method, by the application of a small caus-
tic, has the same inconveniences, and is liable to a much greater
objection; as it is not only attended with more inflammation than
is necessary, but also unnecessarily causes a painful, offensive sore,
producing a slough of part, if not the .whole, of the tunica vagi-
nalis testis.

The human frame is liable to few diseases which have more
frequently exercised the ingenuity of practitioners, to find an easy
and effectual cure for them, than this. Among the various me-
thods which have bee,n proposed, an external discutient has of late
been strongly recommended. It would certainly be a most de-
sirable plan, to get rid of the disease without any operation; but
we know too well how confined our powers are in dispersing col-
lections of fluids within sacculi mucosi, and some kinds of en-
cysted tumors, whose integuments are comparatively thin, and,
therefore, must conceive that much greater power would be re-
quisite to act through the scrotum and thickened tunica vaginalis,
so as to produce absorption of the fluid and cohesion of the tunics.

Hydroceles have been accidentally dispersed by various meaus,
particularly by a blow, by a fever, and by sickness at sea. I do
not entertain the smallest doubt, that the above remedy, which
has been proposed by an ingenious and able practitioner, has pro-
duced the same effect; but I cannot help doubting its capability of
frequently producing it, having myself tried it, and known it tried
by others, several times, without success.

The proportional merit, However, of different remedies, can
never be exactly determined: few men have opportunities of see-
ing a variety of remedies repeatedly tried, and perhaps still fewer
possess a sufficient share of candour, to weigh the merits and defects

'BY MEANS OP AN INJECTION. 193

of each in an equal balance; consequently medical practice is
never settled in any case till it be nearly perfect, or at least till
some one proposed remedy bears no comparison, in point of ex-
cellence, with the rest. Thus, in regard to the treatment of the
hydrocele, though the methods of Mr. Pott and Mr. Else are cer-
tainly great improvements; yet, as some objections may be made
to them, there are at this time surgeons, who have returned to the
old painful practice of incision, and cutting away a part of the
scrotum and vaginal coat.

In this unsettled state of practice it will not, I hope, be thought
improper to subjoin some observations of my own, on this subject,
to those of Mr. Pott; which, however, I should not take the liberty
of intruding into this work, had not Mr. Pott himself so far ap-
proved of the method which I am going to recommend, as to de-
clare to me, not long before his death, his intention of giving it a
fair trial.

It is well known that our forefathers made use of injections for
the cure of hydroceles, and this method is now not out of practice
on the continent; but it is wonderful that a remedy, which may be
made to answer the intention of exciting inflammation to any de-
gree, and is attended wilh no inconvenience, present or future,
should have fallen almost into total disuse in this country: some
of the later English writers on the hydrocele do not mention it;
and if it be noticed by others, it is only to show their disappro-
bation of it.

Injections introduced within the tunica vaginalis testis, into the
urethra, or into any cavity of the body, natural or formed by dis-
ease, are certainly capable of doing mischief; but the mischief
must arise from the nature of the injection: if it be violent and ir-
ritating, it may produce too great inflammation. It is very probablr
that the caustic, and highly stimulating ingredients, which have
been sometimes most injudiciously injected, and confined an un-
reasonable and an unnecessary length of time, have done harm,
and have been the cause of bringing injections in general, and for
the cure of the hydrocle in particular, into discredit: but it is ex-
tremely absurd to infer, from such instances, that oil kinds of in-
jection must hi' pernicious: in the use oflhem ivc are not limited

VOL. II. b b

194 RADICAL CURE OF THE HYDROCELE

to any degree of stimulus. Injections may be found so bland, as
not to offend the most sensible membrane or surface in the human
body; on the other hand, they may be prepared so corrosive as to
inflame, and even to dissolve the most indolent parts; and they be
made to produce any intermediate effect. There is no kind of
stimulus which admits of such various modifications.

Another great advantage of injections is, that they apply them-
selves equally and universally over the whole cavity into which
they are thrown, which no solid body can do.

As I had frequently succeeded in procuring an adhesion and
consolidation of parts in sinuses and other large cavities, by injec-
tions of various kinds, without causing great inflammation, and
had by those means avoided the necessity of extensive divisions
of the skin and integuments, which should be avoided as much as
possible in every part, I conceived that the cure of hydroceles
might be effected by the same gentle means, without deranging,
more than is necessary, the economy of those tender and sensible
organs which are the seat of the disease, and I determined to make
the experiment.

The injection I employed for this purpose is wine, which I made
choice of for several reasons: it had been used with success in
France; the strength of it is never so great as to render it an un-
safe remedy, and it may be readily lowered, according to the
different sensibility of the parts. Thus a vinous injection ap-
peared capable of producing all the good effects which could be
desired, with scarce a possibility of doing harm. The success
which has attended it has more than answered my expectation;
and, from every trial I have made, I have no reason to wish for a
different one: the pain which is produced by it is incomparably
less than by any other operation: it does nothing more than is in-
tended, and the curative effect is equally certain.

In my last edition of these works I inserted a circumstantial
account of my method of using the injection, which was then
in its infancy, and of which I then had doubts; but I have since
experienced such success, that I thought proper to publish a se-

iJV MEANS OF AN INJECTION. 19^

parate account of it, which has been repeated in several editions,
and is now so well known and so universally practised in all parts
of the world, that I think it unnecessary to swell this work with
a repetition of it — I must therefore beg leave to refer whoever
wishes to be further informed of the cure of the hydrocele by in
jection, to my treatise on that subject,

A TREATISE

FISTULA IN ANO,

PREFACE

It has been said, that when a man thinks that he can, by pub-
lishing his opinion, derive any benefit to his fellow-creatures, he
has no reason to be anxious about making an apology for such
publication.

This, within a certain limitation, is true; but, taken in its full
extent, may be urged as an excuse for obtruding that on the world
which may not be worth its acceptance.

Possibly the following sheets may be thought to come within
that predicament.

The only defence I have to make for them is, that from the
most diligent and most frequent inquiry into the general method
of treating the disease in question, I am convinced, that such me-
thod may be considerably improved; that is, may be rendered
less painful, more expeditious, and more successful.

I should be very sorry to have it thought, that I meant, by this,
to signify, that my opinion on this subject is different from that of
all my brethren: I know it is not; I know that there are some
gentlemen of the profession who think of it as I do; but I also
know, that a very different doctrine is inculcated, and a very dif-
ferent method followed, by the majority of writers, practitioners,
and teachers.

The number of those who have had frequent opportunities of
seeing this kind of disease, is not large, compared to that of those
who are daily liable to be called (o the care of it: the number of

200 PREFACE.

those who reflect on what they see or read, and who take the li-
berty of thinking for themselves, is still smaller; so that the pre-
cepts delivered by such as have obtained any degree of reputa-
tion, do almost necessarily become rules of practice to the mul-
titude.

I have, on this occasion, carefully perused almost every writer
of character on the subject; and think, that I may venture to say,
that they are all either defective or erroneous: they either pass
the disease over slightly, and without that regard which it cer-
tainly requires and deserves, or subject it to a method of cure,
which is operose, painful, tedious, and unnecessarily productive
of future evil.

The term Cutting for a Fistula, conveys to a patient a terrible
idea; and this terror is not a little increased by his incapacity of
seeing the part diseased. The majority of writers have greatly
increased, rather than lessened this dread; and as the operation is
(under their directions) sometimes performed, it is, indeed, a
very severe one. A great part of this severity appears to me to
be unnecessary; and I cannot help thinking, that a more serious
reflexion on the parts concerned in the disease, and on its differ-
ent nature, in different states and circumstances, would lead us to

a more rational method of treating it, and to a more easy and ex-
peditious cure.

To point such method out is the intention of the following
Tract,.

In the execution of it, I have sometimes found myself under a
necessity of controverting the opinion of some gentlemen of de-
served eminence: if I have done this with decency and good man-
ners, no apology is necessary. The honour of our art, and the
moral characters of its professors suffer, whenever we pay so blind
deference to any one, as prevents us from using our own judg-
ments, and from declaring freely the results of our inquiries or

PREPACK 2Q1

experiments. Truth, as Lord Bacon has said, is not the child of
authority, but of time. And were we to allow ourselves to sup-
pose (let the subject be what it may, provided it be liable to ex-
periment) that nothing more or new could be taught, it is pretty
clear, that nothing more or new would be learned.

I therefore hope, that the freedom which I have used, either
in relating the opinions, or in objecting to the practice of others,
will not be attributed to an invidious disposition to find fault;
but merely to a desire of being serviceable to mankind in that
way, in which, I flatter myself, that I may be in some degree ca-
pable; and of improving, as much as in me lies, the very neces-
sary and universally useful Science of Surgery.

vol. n. a r.

FISTULA IN ANO

SECT. I.

Clear and precise definitions of diseases, and the application
of such names to them as are expressive of their true and real na-
ture, are of more consequence than they are generally imagined
to be: untrue or imperfect ones occasion false ideas; and false
ideas are generally followed by erroneous practice.

It would be no difficult matter to produce instances of disorders,
whose treatment has, for a great length of time, been accommo-
dated more to the titles imposed upon them, than to their true and
real character: among these my present subject is a most glar-
ing proof.

The custom of giving the appellation of Fistula to every impos-
thumation, and to every collection of matter formed near to the
anus, has, by conveying a false notion of them, been productive
of such methods of treating them, as (though, perhaps, suited to
such idea) are diametrically opposite to those which ought to be
pursued: such as have often rendered those cases tedious and pain-
ful, which might have been cured easily and expeditiously; and
consequently such as have brought disgrace on our art, and unne-
cessary trouble on mankind.

A small orifice or outlet from a large or deep cavity, discharg-
ing a thin gleet or sanies, made a considerable part of the idea,
which our ancestors had of a fistulous sore, wherever seated. With
the term fistulous, they always connected a notion of callosity;
and therefore, whenever they found such a kind of opening yield-
ing such sort of discharge, and attended with any degree of indu-
ration, they called the complaint a Fistula. Imagining this calosi-
fy to be a diseased alteration made in the very structure of the

204 A TREATISE ON THE

parts, they had no conception that it could be cured by any me:,
but by removal with a cutting instrument, or by destruction with
escharotics; and therefore they immediately attacked it with knife
or caustic, in order to accomplish one of these ends; and very
terrible work, by their own accounts, they often made before they
did accomplish it.

Several of the above mentioned circumstances do frequently
attend collections of matter near to the rectum; and therefore,
for want of proper attention to the true nature of the case, the
custom of calling them all Fistulae has generally prevailed, though
without any foundation in truth or nature.

That abscesses, formed near the fundament, do sometimes, from
bad habits, from extreme neglect, or from gross mistreatment,
become fistulous, is certain; but the majority of them have not, at
first, any one character or mark of a true fistula; nor can, with-
out the most supine neglect on the side of the patient, or the most
ignorant mismanagement on the part of the surgeon, degenerate,
or be converted into one.

Collections of matter from inflammation (wherever formed), if
they be not opened in time, and in a proper manner, do often
burst, The hole, through which the matter finds vent, is gene-
rally small, and not often situated in the most convenient, or most
dependent part of the tumor; it therefore is unfit for the discharge
of all the contents of the abscess; and, instead of closing, contracts
itself to a smaller size; and, becoming hard at its edges, conti-
nues to drain off what is furnished by the undigested sides of the
cavity.

This is often the case in the most muscular or fleshy parts ot
the body, where the cellular and adipose membrane does not
abound; but is more particularly so in the neighbourhood of the
anus, where that membrane is large in quantity, well stocked
with fat, and not compressed by the action of any large or strong
muscles.

Why critical defluxions and abscesses are frequently formed ic
this part, is so obvious to every one who considers its natural
structure, that it must be quite unnecessary to enter into an expla-
nation of it: I shall therefore only observe, that when it becomes
the seat of such kind of defluxion. it can make little or no resist-

FISTULA IN ANO. 205

ance, but immediately swells, and becomes' hard to a considerable
extent; and although imposthumation is very frequently the con-
sequence, )et the induration extending itself a good way beyond
the bounds of the abscess, the first suppuration is by no means
equal to the dissolution of such hardness; especially, if, instead of
being opened properly, the skin has been suffered to burst.

The smallness of this accidental orifice, the hardness of its edges,
its being found to be the outlet from a deep cavity, the daily dis-
charge of a thin, gleety, discoloured kind of matter, and the indu-
ration of the parts round about, have all contributed to raise and
confirm the idea of a true fistula.

To this idea, the general treatment of these cases has therefore
been made to accord: upon this has been built the prevailing doc-
trine of free excision, or as free destruction, without any regard
to the original production of the complaint, its particular seat, its
date, or any other attendant circumstances; and without examin-
ing, whether it would not admit a more easy and a more expe-
ditious method of cure. In short, this notion, that all sinuses
near the rectum are necessarily fistulous, has occasioned the pre-
scription of such a manner of treating them, from their very first
appearance, as they can hardly ever stand in need of at any time;
and a mere ill founded supposition, that the induration of the parts
about may be owing to a diseased callosity, is urged as a reason
Cor using them with mora severity than even such state would
require.

SECT. II.

Whoever would obtain a true notion of the disease in question,
must eonsider it under all the forms in which it makes its appear-
ance. These, which are many and various, (both with regard to
aspect, situation, and symptoms,) are what show the different na-
ture of the complaint in different states, and are the circumstances
which ought to regulate a surgeon's conduct in the care of it.

206 A TREATISE ON THE

Sometimes the attack is made with symptoms of high inflam-
mation; with pain, fever, rigor, &c. and the abscess proves truly
critical; that is, it becomes a solution of the fever.

In this case, a part of the buttock near to the anus is consider-
ably swollen, and has a large circumscribed hardness. In a short
time, the middle of this hardness becomes red and inflamed; and
in the centre of it matter is formed.

This (in the language of our ancestors) is called in general a
Phlegmon; but when it appears in this particular part, a Phyma.

The pain is sometimes great, the fever high, the t.umor large,
and exquisitely tender; but however disagreeable the appearances
may have been, or however high the symptoms may have risen,
before suppuration, yet when that end is fairly and fully accom-
plished, the patient generally becomes easy and cool; and the
matter formed under such circumstances, though it may be plenti-
ful, yet is good.

On the other hand, the external parts, after much pain, attend-
ed with fever, sickness, &c. are sometimes attacked with Consid-
erable inflammation, but without any of that circumscribed hard-
ness, which characterised the preceding tumor; instead of which
the inflammation is extended largely, and the skin wears an ery-
sipelatous kind of an appearance. In this the disease is more
superficial, the quantity of matter small, and the cellular mem-
brane sloughy to a considerable extent.

Sometimes, instead of either of the preceding appearances,
there is formed in this part what the French call une suppuration
gangreneu.se ; in which the cellular and adipose membrane is af-
fected in the same manner, as it is in the disease called a Car-
buncle.

In this case the skin is of a dusky red or purple kind of colour;
and although harder than when in a natural state, yet it has by
no means that degree of tension or resistance, which it has either
in the phlegmon, or in the erysipelas.

The patient has generally, at first, a hard, full, jarring pulse,
with great thirst, and very fatiguing restlessness. If the progress
of the disease be not stopped, or the patient relieved by medicine,
the pulse soon changes into an unequal, low, faltering one; and
the strength and the spirits sink in such manner, as to imply

FISTULA IN AN0. 207

great and immediately impending mischief. The matter formed
under the skin, so altered, is small in quantity, and bad in quali-
ty; and the adipose membrane is gangrenous and sloughy through-
out the extent of the discoloration. This generally happens to
persons, whose habit is either naturally bad, or rendered so by
intemperance.

In each of these different affections, the whole malady is often
confined to the skin and cellular membrane underneath it; and no
other symptoms attend than the usual general ones, or such as
arise from the formation of matter or sloughs in the part imme-
diately affected. But it also often happens, that, added to these,
the patient is made unhappy by complaints arising from an influ-
ence, which such mischief has on parts in the neighbourhood of
the disease; such as the urinary bladder, the vagina, the urethra,
the hemorrhoidal vessels, and the rectum; producing retention of
urine, strangury, dysury, bearing down, tenesmus, piles, diarrhoea,
or obstinate costiveness; which complaints are sometimes so press-
ing, as to claim all our attention. On the other hand, large quan-
tities of matter and deep sloughs are sometimes formed, and great
devastation committed on the parts about the rectum, with little
or no previous pain, tumor, or inflammation.

Sometimes the disease makes its first appearance in an indura-
tion of the skin, near to the verge of the anus, but without pain
or alteration of colour; which hardness gradually softens and sup-
purates. The .matter, when let out, in this case, is small in
quantify, good in quality; and the sore is superficial, clean, and
well conditioned. On the contrary, it now and then happens,
that although the pain is but little, and the inflammation apparent-
ly slight, yet the matter is large in quantity, bad in quality, ex-
tremely offensive, and proceeds from a deep crude hollow, which
bears an ill-natured aspect.

The place also where the abscess points, and where the matter,
if let alone, would burst its way out, is various and uncertain.
Sometimes it is in the buttock, at a distance from the anus; at
other times near its verge, or in the perineum; and this discharge
is made sometimes from one orifice only, sometimes from several.
In some cases, there is not only an opening through the skin ex

208 A TREATISE ON THE

ternally, but another through the intestine into its cavity; in others,
there is only one orifice, and that either external or internal.

Sometimes the matter is formed at a considerable distance from
the rectum, which is not even laid bare by it; at others, it is laid
bare only, and not perforated. It is also sometimes not only de-
nuded, but pierced; and that in more places than one. The ori-
ginal seat of the mischief is, in some cases, high up in the pelvis,
near the lower vertebrae of the loins, and the os sacrum; and the
matter comes from parts so diseased, and so out of reach, that the
case is hopeless from the first. These discharges are to some per-
sons salutary, and prove solutions of general diseases, which have
long infested the habit; to others, they often prove fatal, by ex-
hausting the small remains of strength. If the disease has its
foundation in the lues venerea, (which is not a very uncommon
case,) it frequently communicates with the urethra and neck of
the bladder, producing great disturbance and misery to the patient.
And sometimes it happens, that fistulous openings, near the anus,
give discharge to a sanies, proceeding from a cancerous state of
some of the parts within the pelvis.

Whoever attends to this variety of states and circumstances,
must be convinced, that no one particular method can suit them
all; but that in this, as in many other cases, the surgeon's con-
duct must be varied occasionally, and adapted to the exigencies
of each individual,

SECT. III.

It very seldom happens, when inflammatory defluxions are
made on the cellular membrane surrounding the intestine rectum,
that it is in our power to prevent the formation of matter; nor, if
it was, would it often be right so to do; as these abscesses seldom
happen to any body, to whom they are not, at least, a temporary
relief.

AH consideration, therefore, of that kind is generally out of the

FISTULA IN ANO. OQ9

question; and our business, if called to it at the beginning, must
be to moderate the symptoms; to forward the suppuration; when
the matter is formed, to let it out; and to treat the sore in such a
manner, as shall be most likely to produce a speedy and lasting
cure.

When there are no symptoms which require particular atten-
tion, and all that we have to do is to assist the maturation of the
tumor, a soft poultice is the best application. When the disease
is fairly of the phlegmonoid kind, the thinner the skin is suffered
to become, before the abscess be opened, the better; as the indu-
ration of the parts about will thereby be the more dissolved, and,
consequently, there will be the less to do after such opening has
been made. This kind of tumor is generally found in people of
full, sanguine habits; and who, therefore, if the pain be great, and
the fever high, will bear evacuation, both by phlebotomy and
gentle cathartics; which is not often the case of those who are
said to be of bilious constitutions; in whom the inflammation is
of larger extent, and in which the skin wears the yellowish tint
of the erysipelas; persons of such kind of habit, and in such cir-
cumstances, being in general seldom capable of bearing large
evacuation.

The observation is general with regard to erysipelatous inflam-
mations in any part of the body, and is by no means confined to
this.

I may possibly be censured, for stepping out of my way to men-
tion it; but it is a truth of so much importance to many, and I
have seen such melancholy instances from its being not known, or
not attended to, that mv intention must plead my excuse.

This kind of inflammation (I mean the erysipelatous) generally
makes its attack with nausea, vomiting, slight rigor, heat, thirst,
and restlessness.

The quickness of pulse, and heat of skin, are indications for
some degree of evacuation, and indeed sometimes render it requi-
site; but it is a very prevailing opinion with many practitioners,
that these evacuations should be freely made, and frequently re-
peated: in short, that the cure of this kind of inflammation is safe-
ly to be affected by them; which is so far from being true, that

vol. u. d d

210 A TREATISE ON THE

the practice has proved fatal to many. If, for instance, blood be
drawn off in such quantity as the patient's pulse sinks suddenly,
or if his strength be considerably reduced by purging, it is no very
uncommon thing for the inflammation to leave the part first affect-
ed, and for such complaints to come on immediately, as soon
prove destructive, and afford no opportunity to repair the mischief
which the evacuation has produced.

When the inflammation is of this kind the quantity of matter
formed is small, compared to the size and extent of the tumor; the
disease is rather a sloughy, putrid state of the cellular membrane,
than an imposihumation; and, therefore, the sooner it is opened,
the better. If we wait for the matter to make a point, we shall
wait for what will not happen; at least not till after a consider-
able length of time; during which, the disease in the membrane
will extend itself, and, consequently, the cavity of the sinus, or
abscess, be thereby greatly increased.

When, instead of either of the preceding appearances, the skin
wears a dusky, purplish-red colour; has a doughy, unresisting
kind of feel, and is very little sensible; when these circumstances
are joined with an unequal, faltering kind of pulse, irregular
shiverings, a great failure of strength and spirits, and inclination
to dose, the case is formidable, and the event generally fatal.

The habit, in these circumstances, is always bad; sometimes
from nature, but much more frequently from gluttony and intem-
perance. What assistance art can lend, must be administered
speedily; every minute is of consequence; and if the disease be
not stopped, the patient will sink. Here is no need for evacua-
tion of any kind; recourse must be immediately had to medical
assistance; the part affected should be frequently fomented with
hot spirituous fomentations; a large and deep incision should be
made into the diseased part; and the applications made to it should
be of the warmest, most antiseptic kind.

This also is a general kind of observation, and equally applica-
ble to the same sort of disease in any part of the body. Our an-
cestors have thought fit to call if in some a carbuncle, and in
others by other names; but it is (wherever seated) really and tru-
ly a gangrene of the cellular and adipose membrane: it always
implies great degeneracy of habit, and, most commonly, ends ill.

FISTULA IN ANO. 211

Strangury, dysury, and even total retention of urine, are no
very uncommon attendants upon abscesses forming in the neigh-
bourhood of the rectum and bladder; more especially, if the seat
of them be near the neck of the latter.

They sometimes continue from the first attack of the inflam-
mation, until the matter is formed, and has made its way out-
ward; and sometimes last a few hours only.

The two former most commonly are easily relieved by the loss
of blood, and the use of gum arabic, with nitre, &c. But the last,
the total retention, is, while it continues, both fatiguing and
alarming. They who have not often seen this case, generally
have immediate recourse to the catheter; and for this they plead
the authority of precept: but the practice is so essentially wrong,
and I have seen such terrible consequences from it, that I cannot
help entering my protest against it.

The neck of the bladder, from its vicinity to the parts where
the inflammation is seated, and from its being involved in the
same common membrane, does certainly participate, in some de-
gree, of the said inflammation. This will, in some measure, ac-
count for the complaint: but whoever considers the extremely
irritable state of the parts composing that part of the urethra, (if
I may be allowed so to call it,) and will, at the same time, re-
flect on the amazing and well known effects of irritation, will be
convinced that the principal part of this complaint arises from
that cause; and that the disease is, strictly speaking, spasmodic.
The manner in which an attack of this kind is generally made,
the very little distention which the bladder often suffers, the small
quantity of urine sometimes contained in it even when the symp-
toms are most pressing, and the most certain as well as safe me-
thod of relieving it, all tend to strengthen such opinion.*

But whether we attribute the evil to inflammation, or to spas-

a Great and acute as the pain is in the neck of the bladder, and about the
pubes, in a retention of urine, it is not greater, nor more acute than is
sometimes felt in the same parts by those in whose bladder no urine is to be
found, and in whom the catheter may be passed with very little trouble or
resistance. This complaint, which I have more than two or three times
seen, is truly spasmodic ; and, accordingly, always gives way to opium, more
especially if used in the form of a clyster.

212 A TREATISE ON THE

modic irritation, whatever can, in any degree, contribute to the
exasperation of either, must be palpably and manifestly wrong.
The violent passage of the catheter through the neck of the blad-
der (for violent in such circumstances it must be) can never
be right. I will not say that it never succeeds; but I will say, that
it can hardly ever be proper to make the attempt.

If the instrument be successfully introduced, it must either be
withdrawn as soon as the bladder is emptied, or it must be left in
it: if the former be done, the same cause of retention remaining,
the same effect returns; the same pain and violence must again be
submitted to, under (most likely) increased difficulties. On the
other hand, if the catheter be left in the bladder, it will often,
while its neck is in this state, occasion such disturbance, that the
remedy (as it is called) will prove an exasperation of the disease,
and add to the evil it is designed to alleviate. Nor is this all;
for the resistance which the parts, while in this state, make, is
sometimes so great, that if any violence be used, the instrument
will make for itself a new route in the neighbouring parts, and lay
the foundation of such mischief as frequently baffles all our art —
an accident, which I have known happen to those whose judg-
ment and dexterity have never been doubted.

The true, safe, and rational method of relieving this complaint
is by evacuation and anodyne relaxation: this not only procures
immediate ease, but does, at the same time, serve another very
material purpose; which is that of maturating the abscess. Loss
of blood is necessary; the quantity to be determined by the strength
and state of the patient. The intestines should also be emptied,
if there be time for so doing, by a gentle cathartic: but the most
effectual relief will be from the warm bath, or semicupium, the
application of bladders with hot water to the pubes and perineum,
and, above all other remedies, the injection of clysters, consisting
of warm water, oil, and opium. There may have been cases
which have resisted and baffled this method of treatment; but I
have never met with them.

On the other hand, I have seen so great and permanent mis-
chief from the premature use of the catheter, that it would have
been better for the patient to have sunk under the first evil, than
to have lived to experience that variety of misery, to which all

FISTULA IN ANO. 213

they are subject w^o are afllicted with a diseased or injured neck
of the bladder.

A painful tenesmus is no uncommon attendant upon an inflam-
matory defluxion on the parts about the rectum. The frequent use
of the muscles, whose office it is to expel from the gut whatever
is troublesome to it, and by whose action the pans, which make
the seat of the disease, must be continually compressed, make this,
while it lasts, a very disagreeable complaint.

If a dose of rhubarb, joined with a warm anodyne, such as
the conf. mithrid. or such like, does not remove it, the injection
of thin starch and opium, or tinctura thebaic, is almost infallible.

The bearing down, as it is called, in females, as it proceeds, in
this case, from the same kind of cause, (viz. irritation,) admits re-
lief from the same means as the tenesmus.

In some habits, an obstinate costiveness attends this kind of in-
flammation, accompanied, not unfrequently, with a painful disten-
tion and enlargement of the haemorrhoidal vessels, both internally
and externally. While a quantity of hard fasces are detained
within the large intestines, the whole habit must be disordered;
and the symptomatic fever, which necessarily accompanies the
formation of matter, must be considerably heightened. And while
the vessels surrounding the rectum (which are large and numerous)
are distended, all the ills proceeding from pressure, inflammation,
and irritation, must be increased. This is too obvious to need any
explanation; and it must be as obvious, that phlebotomy, laxative
clysters, and a low, cool regimen, must be the" remedies; while a
soft cataplasm, applied externally, serves to relax and mollify the
swollen, indurated piles, at the same time that it hastens the sup-
puration.

These arc, I think, the most material of the complaints which
attend inflammatory deductions and formations of matter about the
anus and rectum. They are indeed most of them symptomatic or
accessory to the original disease: but they are frequently of such
immediate consequence to the ease, and sometimes even to the
safety of the person afflicted, that they require all our attention.
Whoever neglects or mis-treats them, will cause his patient to
suffer a great deal of unnecessary pain, fatigue, and even hazard:

214 A TREATISE ON THE

whoever attends to, and treats them properly, will find that, by
relieving and appeasing these accidental i;ls, he will assist the cure
of the principal complaint, and gain time, instead of losing it.

SECT. IV.

Let us now consider this disease, when the first symptoms
attending the inflammation are gone off, and matter is either formed
and collected, in such manner as to be fit for a surgeon to give dis-
charge to it: or (that opportunity having been avoided or neglected)
it has burst through the parts containing it, and has made its own
way out.

The different states and circumstances produced, either by the
collection of this matter, or by the manner in which it has made
its escape, will necessarily occasion a difference in the manner of
treating the case; and may, for method sake, as well as for the
more perfectly understanding the true nature of the disease, be
reduced to two general heads; viz.

1. Those in which the intestine is not at all interested; and,

2. Those in which it is either laid bare, or perforated.

Let us first suppose the matter to be fairly formed; to have made
its point, as it is called; and to be fit to be let out.

Where such point is, that is, where the skin is most thin, and
the fluctuation most palpable, there the opening most certainly
ought to be made.

Some of our predecessors, either from a fear which almost neces-
sarily accompanies the want of anatomical knowledge, or from an
awkwardness attending the disuse of a cutting instrument, adopted
the method of opening these (as well as most other abscesses) by
caustic.

With all due deference to authority, I will venture to say, that
it is in general wrong; and particularly so in the present case.

It often gives unnecessary pain; and it produces a loss of sub-
stance, and a kind of cicatrix, which is not only unseemly, but
frequently proves a lasting inconvenience.

FISTULA IN ANO. ' 215

Some of the patrons of potential tire do, indeed, give a specious
kind of reason for its use; viz. that it makes a more large and free
opening for the discharge; and that, by the time the eschar is
separated, the hollow underneath is generally more than half filled
up.

In a few (very few) particular cases, where the destruction of
glandular parts may become necessary, after the eschar is thrown
off, (as in the case of venereal buboes,) there may be some force
in this argument, and caustics may be found useful; but in the
present case, and in most others, in which they are freely and fre-
quently applied, they appear to me to be highly improper; as they
necessarily occasion a loss of parts, and a kind of eschar, which
is, in general, an indelible blemish, to say no worse. And with
regard to the particular circumstance of the hollow being filled
almost up, by the time the eschar is separated, if the surgeon will
dress an abscess, opened by incision, in the same easy, superficial
manner he does one opened by caustic, he will find the consequence
to be the same. But (I know not why) a notion has long prevailed,
that an abscess opened by a knife must be immediately crammed
and stuffed with dressings, while that on which a caustic has been
applied must be let alone until the eschar casts off. Let the one
be treated as the other is, (and as they both ought to be,) and the
event will be found to be alike in each; excepting this material
difference in favour of the knife, that it will not necessarily occasion
any destruction of parts, loss of substance, nor any deformity which
is at all comparable with what must follow the use of the caustic.

In making the opening; the knife or lancet should be passed in
deep enough to reach the fluid, and, when it is in, the incision
should be continued upward and downward, b in such a manner as
to divide all the skin covering the matter. By these means, the
contents of the abscess will be discharged at once; future lodge-
ment of matter will be prevented; convenient room will be made
for the application of proper dressings; and there will be no

b When I say upward and downward, I suppose the patient to stand on his
feet, with his legs and thighs straight, and his body leaning forward over a
table, or a bed ; which posture gives the fairest view of the parts ; and puts
them into the best position for the operation, as well as for the operator.

216 \ TREATISE ON THE

necessity for making the incision in different directions, or for
removing any part 'of the skin composing the verge of the anus.

Notwithstanding that all these collections of matter are generally
called by the name of Fistula?, and are all supposed to affect the'
intestinum rectum, yet it is very certain that the seat of the abscess
(the place where the matter is formed) is sometimes at such dis-
tance from the gut, that it is not at all interested by it; and that
none of these cases either are, or can be, originally fistulae.

In this state of the disease, we have no more necessarily to do
with the intestine, than if it was not there; the case is to be con-
sidered merely as an abscess in the cellular membrane, which
will require (in the usual phrase) to be digested, incarned, and
(if practicable) healed without meddling with the rectum in any
maimer.

As this is a matter of some importance to the patient, it is
worth a little consideration.

Suppose an abscess formed in the neighbourhood of the rectum,
which, after a certain degree of swelling and inflammation, ripens,
or comes to a point, somewhere near to the verge of the anus.
Suppose also a large and convenient opening to hare been made
by a simple incision; the contents of the abscess to have been
thereby discharged; and a sore or cavity produced, which is, per-
haps, considerable in size; this cavity is to be filled up in such
manner, as to produce a firm and lasting cure.

The frequent use of the term filling up, and the generally re-
ceived opinion, that the induration of the parts about is a diseased
callosity, appear to me to have been the two principal sources of
error and misconduct in these cases.

Wherever matter is formed in consequence of inflammation, it
always leaves, upon being let out, a proportional hollow, and
some degree of induration. The former of these is of different
size, according to the quantity of matter; and the latter depends
both on the degree of previous inflammation and the more or less
perfect suppuration of the abscess.

The generally received opinion, with regard to these two cir-
cumstances, (hollow and hardness,) is, that the former is caused
entirely by loss of substance; and the latter (as I have already ob-
served) by diseased alteration in the structure of the parts.

FISTULA IN ANO. £17

The consequence of which opinion is, that as soon as the mat-
ter is discharged, the cavity is filled and distended, in order to pro-
cure a gradual regeneration of flesh, and the dressings, with which
it is so filled, are most commonly of the escharotic kind, intended
for the dissolution of hardness.

The practice is a necessary consequence of the theory. Who-
ever supposes diseased callosity, and great loss of substance, will
necessarily think himself obliged to destroy the former, and to
prevent the cavity, formed by the latter, from filling up too hasti-
ly. On the other hand, he who considers this matter as it really
is; that is, he who regards the cavity of the abscess as being prin-
cipally the effect of the gradual distraction and separation of its
sides, with very little loss of substance, compared with the size of
the said cavity; and who looks upon the induration round about,
as nothing more than a circumstance which necessarily accom-
panies every inflammation in membranous parts, more especially
in those which tend to suppuration; will, upon the smallest re-
flexion, perceive, that the dressings applied to such cavity ought
to be so small in quantity, as to permit nature to accomplish that
end which she always aims at as soon as the matter is let out
(I mean, the approach of the sides of the cavity toward each
other); and that such small quantity of dressings ought to consist
of materials proper only to encourage easy and gradual suppura-
tion.

This is a fact so obvious to common sense, that it must appear
to every one who will coolly and impartially consider it.

What is the part in which the disease is seated? and what are
(he alterations which such disease produces? The part is mere
cellular membrane; and the alteration is obstruction and in-
flammation, ending in the formation of matter. But do these cre-
ate any new body? do not the sides of the abscess still remain cellu-
lar and adipose membrane, only inflamed, thickened, hardened,
and rendered purulent? can such alteration require any thing more
toward restoring the parts to a natural state, than a free stippura-.
tion from the parts so altered? or can it make extirpation or de*
struction necessary? Most certainly it cannot. How then is sup-
puration to be produced and maintained? Not by thrusting in
such applications, as by their quantity distend, and by their quality

VOL. II.

218 A TREATISE ON THE

irritate and destroy; but by dressing lightly and easily with such
as appease, relax, and soften.

The fact is capable of experiment; and every man who will
make it, that is, who will try the different methods, and attend to
the consequences, must be able to determine it; unless blinded by
prejudice, or influenced by a worse moiive.

A moment's attention to the conduct of nature, when left te
herself, and not interrupted by art, will, perhaps, set this matter
in a clearer light.

When an abscess of this kind is opened by a surgeon, the ca-
vity is found proportioned to the contents; and, consequently, if
the quantity of matter be large, ihe hollow is considerable. If this
hollow be immediately filled with dressings (of any kind,) the
sides of it will be kept from approaching toward each other, or
may even be further separated. Bui if this cavity be not filled,
or have little or no dressings of any kind introduced into it, the
sides immediately collapse; and coming nearer and nearer, do, iu
a very short space of time, convert a large hollow into a small si-
nus. And this is also constantly the case, when the matter, instead
of being let out by an artificial opening, escapes through one made
by the bursting of the containing parts.

It is indeed true, that this sinus will not always (and particular-
ly 4n the disease I am now speaking of) become perfectly close,
and heal; but. the aim and conduct of nature is not, therefore, the
less evident; nor the hint, which art ought to borrow from her,
the less palpable.

In this, as in most other cases where there are large sores,
or considerable cavities, a great deal will depend on the patient's
habit, and the care that is taken of it; if that be good, or if it be
properly corrected, the surgeon will have very little trouble in
his choice of dressings; all that he will have to do will be, to take
care that they do not offend either in quantity or quality; but if
the habit be bad, or injudiciously treated, he may use the whole
farrago of externals, and only waste his own and his patient's
time.

In short, all these cases are, at first, mere abscesses; the conse-
quences of inflammation, and require no other treatment than
what would be proper in the same kind of case in all other parts.

FISTULA IN ANO. 219

Some few of them are so circumstanced, with regard to the intes-
tine, that it is quite unnecessary to meddle with it at all; but whe-
ther that be the case or not; whether the division of the rectum
become a necessary part in the cure, or not; they, most certainly,
do not deserve the name of fistulae, nor require that sort of treat-
ment which fistula? are said and thought, to stand in need of;
though by being, from their very first appearance, supposed to be
such, they are frequently, by mismanagement, rendered truly fis-
tulous.

By this (that is, by light, easy treatment,) large abscesses form-
ed in the neighbourhood of the rectum will sometimes be cured
without any necessity occurring of meddling with the said gut.
But it much more frequently happens, that the intestine, although
it may not have been pierced or eroded by the matter, has yet been
so stript or denuded, that no consolidation of the sinus can be
obtained, but by a division; that is, by laying the two cavities,
viz. that of the abscess and that of the intestine, into one.

The necessity of doing this, may, in many cases, be known
by the surgeon at first; that is, when he opens the abscess he may
find the intestine so bare, and in such state, as plainly to prove
that he will not be able to effect a cure without the operation; in
other instances, he may have reason at first to flatter himself with
success, and be disappointed.

When the former is the case; when the gut is found to be in
such state, that there is no reason to expect a cure, without its
being divided; that operation had better (on many accounts) be
performed at the time the abscess is first opened, than be deferred
to a future one. For if it be done in the manner in which I will
venture to say that it always may, it will add so little to the pain
which the patient must feel by opening the abscess, that he will
seldom be able to distinguish the one from the other, either with
regard to time or sensation; whereas, if it be deferred, he must
either be in continual expectation of a second cutting, or feel one
at a time when he does not expect it.

The intention in this operation is to divide the intestine rectum
from the verge of the anus, up as high as the top of the hollow in
which the matter was formed; thereby to lay the two cavities of
the gut and abscess into one; and by means of an open, instead of
si hollow or »inuous sore, to obtain a firm and lasting cure.

220 A TREATISE ON THE

Ingenious, mechanical, and whimsical people, have often bu-
sied themselves in inventing instruments for this purpose: the
syringotomy, the cultellus falcatus, the probe-razor, &c. have all
at times been in use; scissors also of various kinds, both straight
and crooked, have been employed in this operation; the three first
may be made to serve the purpose very well; but* for the last (the
scissors,) there is in this, as well as in almost every operation in
which they are frequently used, a palpable objection; viz. that by
pinching at the same time that they cut, they occasion a great
deal of unnecessary pain. They are, I know, in great use with
many, who, if they were deprived of their probe-scissors, would
think themselves incapacitated from doing business; but they are,
upon all occasions, where mere division is required, a very bad in-
strument; the}- may assist an aukward or an unsteady hand, but
are more tit for a farrier than for a surgeon.

In all chirurgic operations, the instrument made use of cannot
be too simple, nor too keen; and, if possible, should never be out
of the sight or the direction of the finger of the operator; and,
whenever it is (as must sometimes necessarily be the case), it is
liable to some degree of uncertainty. Scissors introduced into
the rectum are always in this predicament; and are, therefore, (as
well as on account of their pinching quality,) bad.

The curved, probe-pointed knife, with a narrow blade, I have
always found to be the most useful and handy instrument of any.
This, introduced into the sinus, while the surgeon's fore finger is
in the intestine, will enable him to divide all that can ever require
division; and that with less pain to the patient, with more facility
to the operator, as well as with more certainty and expedition,
than any other instrument whatever. If there be no opening in
the intestine, the smallest degree of force will thrust the point of
the knife through, and thereby make one; if there be one already,
the same point will find and pass through it. In either case, it
will be received by the finger in ano; will thereby be prevented
from deviating; and, being brought out by the same finger, must
necessarily divide all that is between the edge of the knife and

c The late Mr. Frcke invented an instrument for this purpose ; but it was.
^ipon trial, found to cut the operator's finger with so much more certaintv
than the patient's intestine, that it has long; been laid aside.

FISTULA IN ANO. 2£l

the verge of the anus; that is, must by one simple incision (which
is made in the smallest space of time imaginable) lay the two
cavities of the sinus ami of the intestine into one.

Autbort make a very formal distinction between those cases
in which the intestine is pierced by the matter, and those in
which it is not; but although this distinction may be useful when
the different slates of the disease are to be described, yet in prac-
tice, when the operation of dividing the gut becomes necessary,
such distinction is of no consequence at all; it makes no altera-
tion in the degree, kind, or quantity of pain which the patient is
to feel; the force required to push the knife through the tender
gut is next to none; and when its point is in the cavity, the cases
are exactly similar.

This is the only operation which (in ihe circumstances under
our present consideration) ever can be necessary; and this appears
to me to be the safest, easiest, and most expeditious method of
performing it.

I know that it is contrary to the opinion and practice of many
who think that the removal of some part, both of the intestine
and of the verge of the anus, is necessary in these cases; but long
and repeated experience has convinced me of the contrary; and I
shall, in the next section, have occasion to speak more particu-
larly to that point.

Immediately after the operation, a soft dossil of fine lint should
be introduced (from the rectum) between the divided lips of the
incision, as well to repress any slight haemorrhage, as to prevent
the immediate re-union of the said lips; and the rest of the sore
should be lightly dressed with the same. This first dressing should
be permitted to continue, until a beginning suppuration renders it
loose enough to come away easily; and all the future ones should
be as light, soft, and easy as possible; consisting only of such ma-
terials as are likely to promote kindly and gradual suppuration.
The sides of the abscess are large; the incision must necessarily,
for a few days, be inflamed; and the discharge will, for some time,
be discoloured and gleety. This induration, and this sort of dis-
charge; are often mistaken for signs of diseased callosity, and an
discovered sinuses; upon which presumptions, escharotics are
freely applied, and diligent search is made for new hollows: the

222 A TREATISE ON THE

former of these most commonly increase both the hardness and the
gleet; and by the latter new sinuses are sometimes really pro-
duced. These occasion a repetition of escharotics, and, perhaps,
of incisions; by which means, cases which at first, an'd in their
own nature, were simple and easy of cure, are rendered complex
and tedious.

That this is the truth, without exaggeration is well known to
many; and whoever will look over the writings of some of
our immediate predecessors, or even of some of our contem-
poraries, will find that immediately after pinching and snip-
ping the gut with scissors, we are directed to fill the incisions
with lint; and, after having distended the cavity by such means,
to dress in future with such medicines as, though used under the
specious names of digestives, detergents, &c. do really inflame
and irritate the parts to which they are applied, and retard, in-
stead of encouraging, a kindly suppuration.

Among these, the mercurius piaecipitatus ruber stands princi-
pal: this seems to have been the great external specific of most of
our immediate predecessors, and to have been used by them for
the very different purposes of destruction and restoration. With
this, either in dry powder, or mixed with unguent, the tents,
pledgets, &c. with which they dressed these sores were spread or
embued; with this they dressed the recently divided lips of the
wound in the intestine, and with this they filled the whole cavity
of the abscess.

That the same practice still too much prevails, they who please
may be convinced. 11

I would beg leave to ask any patron of this method of dressing,
what he would say to a man, who shall order a large tent, well
charged with precipitate, to be thrust up the undivided, un-
wounded rectum of a person, who, from any cause whatever, had
an inflammatory defluxion on the haemorrhoidal vessels and inside
of the said gut? Would he not say that such tent would prove a

d Mr. De la Faye says : " Si les chairs s'elevent trop, on les consumera
avec la pierrc infernale ;" and in muny books of reputation, the butyrum
antimonii, the trochisci e minio, the pulvis angelicus, &c. are prescribed for
frequent use.

FISTULA IN ANO. 223

fatiguing, inflammatory suppository? and would he not be right in
saying so? Is then the rectum rendered less sensible, and less ir-
ritable, by being wounded? Or can that very application, which
proves a painful stimulus to a gut not divided, become an easy
digestive to one that is? If any man thinks that it will, I would
advise him to make the experiment on himself; and I would then
appeal to the testimony of his own unprejudiced sensations.

In short, lo quit reasoning, and speak to fact only: In the great
number of these cases, which must have been in St. Bartholo-
mew's hospital, within these ten or twelve years, I do aver, that
I have not met with one in the circumstances before described, that
has not been cured by mere simple division, together with light;,
easy dressings; and that I have not, in all that time, used, for this
purpose, a single grain of precipitate, or of any other escharotic.

Why is it that we hear so much of miracles performed by the
paste of one quack? and by the injections, oils, and balsams of
others? when we all know, that there is nothing specific for the
cure of this disease in their compositions; and when we also know
that the venders of these remedies are people whose ignorance in
matters of physic and surgery is below all notice.

That these cures are much more frequently talked of than made,
I well know; but that some few people, who have been long and
unsuccessfully treated by surgeons, have got either well, or better,
under the very negligent management of some of these quacks, is
an incontestible truth; and very strange it is, that we do not see
why.

Fas est et ah hoste doceri.

The truth is, that, while we are looking for what these people do,
we (if I may be allowed the phrase) overlook what they do not
do. It is true, we cannot find any specific quality in the strange
jumble of ingredients which they put into their internal remedies;
nor any particularly sanative one in their injections, balsams, &c.
and therefore are surprized at even the few instances of their suc-
cess; but still overlook the one single circumstance by which the
good is produced.

It is, and ever must be, a first principle in quackery, to disap-

224 A TREATISE ON THE

prove and condemn whatever has been clone before, be it right or
be it wrong; and it is also necessary for quacks, to avoid all con-
nexion with those who are called Regular Practitioners; as well in
order to have the sole management of the patient, as to avoid in-
spection.

For these reasons, they always order all former dressings to be
immediately thrown aside and disused; and not having in general
ingenuity enough, even to seem to apply others with any degree of
judgment or dexterity, they make use of a mere superficial plaster,
ointment, or injection; that is, without intending any such thing,
upon an honest or a rational principle; they, for want of knowing
what to do properly, leave the conduct of the sore to nature; who,
when the impediment of dressings (which often offend either in
quantity or quality) are removed, will do much more than her
too officious assistants believe.

That the very few cures, which we have heard so much of, are
produced in this manner, I am convinced; and so I am, that many
of those which are thought by several practitioners to have been
brought about by a multiplicity of dressings crammed in tight, and
endeavoured to be kept so, by all the caution of compress and
bandage, are very frequently effected by the constant and gene-
rally successful endeavours of nature to thrust them forth again; or,
at least, so to displace them, that she gradually gets opportunities
of doing her own business, in spite of the impediments of art.
The business of good surgery is to assist nature; but she will, some-
times, get the better even of the worst.

Usque recurret,
Fj mala perrumpet, furtim fastidia victrix.

SECT. V.

In the preceding section, I have supposed the matter of the
abscess to have been formed and collected; but still to have been

FISTULA IN ANO. 225

contained within the cavity, until let out from thence by an inci-
sion.

I am now to consider it, as having made its own way out,
without the help of art.

This state of the disease is also subject to some variety of appear-
ance; and these different appearances have produced, not only a
multiplicity of appellations, but a groundless supposition also of a
variety of essentially different circumstances.

When a discharge of the matter by incision is too long delayed
or neglected, it makes its own way out, by bursting the external
parts somewhere near to the fundament, or by eroding and making
a hole through the intestine into its cavity, or sometimes by both.
In either case, the discharge is made sometimes by one orifice only,
and sometimes by more, Those, in which the matter has made
its escape by one or more openings, through the skin only, are
called blind, external fistulas; those in which the discharge has
been made into the cavity of the intestine, without any orifice in
the skin, are named blind, internal; and those which have an
opening both through the skin and into the gut, are called complete
fistulas.

This is the language of all writers, as I have already observed;
and thus, all these cases are deemed fistulous, when hardly any of
them ever are so; and none of them necessarily. They are still
mere abscesses, which are burst without the help of art; and, if
taken proper and timely care of, will require no such treatment as
a true fistula may possibly stand in need of.

The most frequent of all are what are called the blind external,
and the complete. The method whereby each of these states may-
be known, is, by introducing a probe into the sinus by the orifice
in the skin, while the fore-finger is within the rectum: this will
give the examiner an opportunity of knowing exactly the true state
of the case, with all its circumstances.

Whether the case be, what is called a complete fistula, or not;
that is, whether there be an opening in the skin only, or one there,
and another in the intestine, the appearance to the eye is much
the same. Upon discharge of the matter, the external swelling
subsides, and the inflamed colour of the skin disappears; the ori-
fice, which at first was sloughy and foul, after a day or two are

vol. it. f f

226 A TREATISE ON THE

past, becomes clean, and contracts in size; but the discharge, by
fretting the parts about, renders the patient still uneasy.

As this kind of opening seldom proves sufficient for a cure,'
(though it sometimes does,) the induration, in some degree, remains;
and if the orifice happens not to be a depending one, some part of
the matter lodges, and is discharged by intervals, or may be pressed
out by the fingers of an examiner. The disease, in this state, is
not very painful; but it is troublesome, nasty, and offensive: the
continual discharge of a thin kind of fluid from it, creates heat,
and causes excoriation in the parts about; it daubs the linen of the
patient; and is, at times, very fetid: the orifice also sometimes
contracts, so as not to be sufficient for the discharge; and the
lodgement of the matter then occasions fresh disturbance.

The means of cure proposed and practised by our ancestors
were three; viz. caustic, ligature, and incision.

The intention in each of these is the same; viz. to form one ca-
vity of the sinus and intestine, by laying the former into the latter.

Fear of haemorrhage, in making a large division of parts, and a
design to destroy callosity, gave rise to the use of caustics for this
purpose. By the introduction of them in different forms and man-
ners into the sinus, that part of the intestine which divides its
cavity from that of the abcess is intended to be destroyed; and
thereby the proposed end of making one cavity of two is to be
accomplished; while at the same time the supposed callosity is
to be wasted. For this purpose, some of the most fatiguing and
painful escharotics have been prescribed and used; the pulvis an-
gelicus, the lapis infernalis, and troches and pastes made with
sublimate, arsenic, &c. But the method is so cruel, so tedious,
and so inexpert, that I hope it is by this time totally out of use: it
was founded- in error, tends only to mischief, and I will not waste
the reader's time in saying any thing more about it. f

f Dr Daniel Turner, who practised surgery within these few years, used
this method in its full extent. In his works may he found an account of hia
forming tents of t lie trochisci e minio, and thrusting them into the sinus, there
to remain till they hud produced a sufficient eschar. In tiie same writer are
accounts of strong probe-scissors, made to cut through parts of a considera-
ble thickness, and where the external orifice was at a great distance from the
anus; and of an iron scoop, made (to use the doctor's own words) like a

* f ISTULA IN ANO. 227

The terror which a cutting instrument necessarily carries with
it, the fear of a flux of blood from some considerable vessels, toge-
ther with a strange, nonsensical opinion, that a gradual division of
the parts was followed by a more sound cure, than an immediate
one by cutting, produced the coarse, unhandy method by ligature.
The manner of using it was this: A probe, or needle, (according
to the complete or incomplete state of the supposed fistula,) armed
with a strong ligature, was introduced, either naked or in a can-
nula, by the orifice in the buttock, and brought out at the anus,
by the operator's finger: when that was done, the two ends of the
said ligature were tied together, in such manner, and at such re-
peated times, as by degrees to cut through all that was between
its loop and its knot; that is, all that part of the intestine which
was next to the sinus.

Among writers on this subject will be found very formal direc-
tions about the proper time of the year for performing this opera-
ation, as well as concerning the proper materials where-
with to make the ligature. But as the whole operation is,
on every principle of ease, expedition, safety, or certainty, unfit
for practice, it would be an abuse of the reader's patience to dwell
any longer upon it. e

The third method is that by incision.

cheese-monger's taster, to be thrust up the rectum, and assist in the division
of it. What ideas this gentleman had of the disease, or of human sensation,
I cannot imagine. The same gentleman, speaking of the use of this iron
scoop, tells us, that when he used it on one particular patient, the man
thought that the Doctor was only thrusting up the dressings. It is no diffi-
cult matter to conceive what kind of dressings this man must have been ac-
customed to, who could not distinguish between the application of them and
the thrusting up an iron scoop.

S See Celsus, whose account of the method by ligature has been followed
by most of the writers since. " In hasdemisso specillo, ad ultimum ejus ca-
" put incidi cutis debet ; dein novo foramine specillum educi lino seqtiente ;
" quod in aliam ejus partem, ob id ipsum perforatum, conjectum sit : ibi
" linum apprehendendum, ligandumque cum altero capite est ; ut laxe cutem,
"quae super fistulam est, teneat : idque linum debet esse crudum, et du-
" plex, triplexve, sic tortum ut unitas in eo facta sit. Interim autem licet
" negotia agere, ambulare, lavare, cibum capere, perinde atque sanissi-
« mo," &c.

228 A TREATISE ON THE

I have already given my opinion on what appears to me to be
the best and most proper method of dividing the intestine, in the
case of a collection of matter formed juxta anum.

The intention to be aimed at by incision in the present case
is exactly the same, and (I think) ought to be executed in the same
manner. I never saw that another kind of operation was neces-
sary; I have not for many years performed any other; and I do
not recollect a single instance in which it has failed to produce a
cure, in such cases as were curable by any means.

If, therefore, I intended to give my own opinion merely on this
subject, I should say, the same division of the intestine, and with
the same instrument, is all that is required; and, referring my
reader back to the preceding section, should give him no further
trouble on this head. But as I find my sentiments in this matter
are somewhat different from those of many, I must beg leave to be
indulged in the use of a few words.

I have said, that in whatever manner, or with whatever instru-
ment, the intestine be divided, the intention is the same; viz. to
lay the cavity of the abscess into that of the gut, and thereby to
convert a hollow sinus sore into an open one; preventing, by the
same means, (he future lodgement of matter, and giving ropm for
the application of proper dressings.

The two cases (a collection of matter and a sinus,) seem to me
to require exactly the same treatment; and I have never found it
fail of being equally successful in both; that is, I never found that
the matter, having found its own way out, made any other opera-
tion on the gut, except the mere simple division, at all necessary.

But it is said, and that by authors to whom great regard is due,
that this is not all that is requisite, especially in the present cir-
cumstances; that this will not produce a cure, or assure success;
that mere division of the intestine is not sufficient; and that, un-
less we cut out, remove, and extirpate a portion both of the said
intesiine, and the skin constituting what is called the verge of
the anus, a firm and lasiing cure will not follow. This is the
doctrine of writers of eminence, and the practice of a large body
of surgeons.

When I have mentioned the names of Cheselden, De la Faye,

FISTULA IN ANC. 229

and Le Dran, I need not cite any others of less note. The first
of these was a gentleman whose reputation in his profession was
great; the two latter are in as high character now in France.
The influence of these upon their readers must be considerable;
and therefore it becomes a matter of the more importance that
their doctrine be just and defensible.

The methods which these gentlemen have proposed, and which
have been by many adopted, are somewhat different from each
other, but do all tend to the same purpose, are all calculated to
prevent imaginary evils, and are all productive of real ones.

Mr. Cheselden, in the last edition of his Anatomy, says —
" The true fistula runs between the muscular and inner coat of
" the rectum: it is cured by opening it the whole length into the
" cavity of the gut; but it is yet better, if it can be done, to extir-
" pate all that is fistulous and scirrhous; for that is a sure way to
" make one operation perfect the cure."

In his observations, published at the end of Mr. Gataker's
translation of Le Dran's Surgery, Mr. Cheselden describes a me-
thod of his own inventing, by the introduction of one blade of a
pair of polypus-forceps into the sinus, and of the other into the
rectum; by which means a certain portion of the intestine is held
fast between the chops of the instrument, in order to be cut out
with the scissors.

After having given an explanation of a plate, designed to repre-
sent the forceps introduced in such a manner as to hold the piece
of intestine fast, he adds — " I formerly cut out a pyramidal piece
" in the manner here described; but I find this way with the
" forceps much more convenient, and more easy to be executed."
How much this method, may be preferable to that which Mr,
Cheselden used to practise, I know not; but I will venture to
say, that this more easy method is horridly painful, is opcrose, and
absolutely unnecessary towards obtaining a cure.

The wound, that is, the orifice of the sinus in the buttock, is,
by Mr. Cheselden's direction, to be first dilated with a sponge
tent; then one of the blades of a pair of large polypus forceps is
to be thrust up the sinus, while the other within the intestine
pinches it between them; and then this piece, so pinched, is to be
snipped out by the repeated attacks of a pair of scissors. A very

230 A TREATISE ON THE

tedious and very painful operation this must necessarily be; and, by
Mr. Cheselden's own account, not always successful: for although
he does say — " The operation being thus performed, I have never
" found wanting a second cutting;" yet he immediately adds —
" If, after this operation, there is still an internal discharge into
" the gut, it may be an useful issue; and continue the benefit which
" nature designed by the disease. h We should also be very care-
" ful not to perform it when the patient is troubled with the piles;
" for I have known one in that case bleed to death."

It would be no difficult matter to make great objections to this
method of operating, even if the one thing intended by it was ne-
cessary; I mean the extirpation of a portion of the rectum. This
end might certainly be obtained by easier means; but as that is
not the case, as such extirpation appears to me to be totally unne-
cessary, I shall not enter into it.

Mr. De la Faye, a practitioner and writer of eminence in
France, and a gentleman to whom the chirurgic. world is much
indebted, is a warm patron of the practice of cutting away
both a part of the intestine and of the skin composing the
verge of the anus. After the external incision, necessary for
letting out the matter, has been made, he says — " Si lespus a fait
" un progres considerable du cote de la fesse, on y fera une autre
<c incision, qui tombera. perpendiculairement sur l'incision longitu-
*' dinale; on coupera les angles forme par ces incisions, pour ren-
" dre l'exterieur de la playe plus large que le fond, et pour panser
' plus aisement." ' If the matter has extended itself considerably
* toward the buttock, another incision should be made, in such
4 manner as to cross the former; the angles formed by which inci-
c sions should be cut away, as well to render the external part of
' the wound larger than the internal, as to give room for the more
c convenient application of dressings to the sore.'

h This is a method of making an issue to which few people would (I be-
lieve) choose to submit ; especially if they consider that they might have en-
joyed all the benefit of it, without any operation at all, merely by leaving
their disease to nature. The same gentleman, speaking of the intestine
rectum, tells us, that he once applied a caustic lengthways on the inside of
the inverted gut, to cure a prolapsus ; and adds, that it proved successful.
This I am almost sorry for, lest Mr. Cheselden's authority should tempt any
other person to make the same .attempt.

FISTULA IN ANO. 231

If M. De la Faye had ever, in his own person, had the misfor-
tune to experience the inconvenience arising from the loss of
skin near to the fundament; or had he attended to that which it
produces to those, who, either from choice or necessity, ride or
walk much, I am inclined to believe he would have been more
sparing of it.

For the first three or four days, this kind of incision does, cer-
tainly, render the applications of dressings more convenient; be-
cause the wound is thereby considerably enlarged: but as soon as
digestion has softened the edges of the single perpendicular inci-
sion, that difference ceases; and the dressings may be applied
with equal facility to the one as to the other.

After this period is past, the difference between the two is,
indeed, much more considerable; the cutting away the angles,
adding not a little to the length of time requisite for a cure, ren-
dering the sore much larger and more troublesome, and subjecting
the patient, very often, to great inconvenience, arising from the
kind of cicatrix whfch it necessarily produces.

Mr. De la Faye, after having described the manner of passing
the probe, or the sulcated director, in order to make a simple lon-
gitudinal division of the intestine, adds — " On ne se contente pas
" aujourd'hui de couper la fistule entre les deux extremites du
u stilet: on fait une incision qui renferme dans son circuit ces
" deux extremites; et par le moyen de laquelle, en les tirant en
11 meme temps, on emporte toute la fistule, qui se trouve comme
" embrochee dans 1'anse formce par cette instrument: 1 on fait
" ensuite, a la partie inferieure de la playe, une incision, qui sert
" comme de goutiere a la suppuration." The present practi-
tioners ' do not content themselves with merely dividing the

■ It might be supposed, from the manner in which this is delivered, that
the method was a modern invention; whereas it is, on the contrary, a very
old one. Gnido's description of it is as follows: — " Penetrantes fistulae (se-
" cundum lthazin) non sananter, nisi cum ligatione, et extractione cum
" falce. *

" Modus incisionis cum falce est, quod extrahatur cum chordula immissa

" extra quantum possibile erit intestinumcomprehensum per ipsam chordu-

"lam; et post intromitlendum positum ab Albucasi bene scindens; totum

" illud, quod comprehensum est cum chordula scindatur; ita, quod chor-

" dula cxpediatur."

Gttido.

232 A TREATISE ON THE

' sinus; but making use of the probe as a.kind of loop, they pull

* the parts towards them, and then, by a free and almost circular
' incision, cut out the whole fistula; after which they make such

* an incision in the lower part, as may best serve the purpose of
' a free discharge of matter.'

This method, as far as regards the mere operation, is certainly
preferable to that with the forceps and scissors; but it produces
the same destruction of the parts, and the same future inconve-
niences: like that, it is built upon a supposition, that such a re-
moval of parts is necessary toward a cure; and, therefore, like
that, stands upon a supposition which is not true.

The same gentleman, in another paragraph, admits, that this
method of operating is not proper in certain circumstances (which
circumstances cannot possibly render the disease easier of cure;)
and in such case advises the mere longitudinal section of the
gut. — " Neanmoins, le canal fistuleux pourroil eire si profond, ou
" le trou exterieur de la fistule dans un lieu de la fesse si eloigne
" du fondement, qu'en faisant l'operation de la maniere qu'on
" vient de dccrire, on emporteroit une trop grande portion de la
" substance. En ce cas on ouvre sur une fonde canelee la fistule
" dans sa longueur," &c. ' Nevertheless, the fistulous hollow may
' be so deep, or the external orifice in the buttock at such distance
' from the anus, that, if the operation be performed in the manner
'just described, it would occasion too large a loss of substance.
' In this case, the sinus must be opened lengthways, by means of

So also Brunus, having described the method by ligature, goes on to that
by incision.

" Operatio autem secundi modi est, ut non stringatur spacus[the ligature]
" sicut narratum est ad incid'endas carnes, sed ligentur tantum ipsius extre-
" mitates simul, et ut sit iste spacus fortior et grosior illo qui carnes incidit,
" deinde extende spacum cum una manuum tuarum versus exteriora, et cum
" altera manu tua incide illas carnes quae sunt inter illas duas extremitates,
" spaci, cum instrumento curvx extremitatis."

This is exactly what is now by some called cutting upon the wire ; and I
have seen in the hands of a very ingenious gentleman a single instrument,
very capable of executing all this purpose ; thai is, of cutting out ten times
as much as ever can be necessary.

The same account is to be found in Lanfranc, Rogerius, and most of the old
writers ; who, in this, as in most other instances, have done little more than
copy each other.

FISTULA IN ANO. 233

v a grooved director.' Mr. De la Faye does not indeed say, in
express terms, that this longitudinal division will be sufficient for
a cure; but I will venture to say for him, that I know, from re-
peated experience, that it will. The observation, therefore, which
this gentleman has made, concerning the 'loss of substance, is not
only just and true in itself; but it is also an observation, which, if
properly attended to, will lead to a truth which he does not seem
to have been sufficiently apprised of; which is, that every opera-
tion of this sort (that is, every extirpation of parts) is unneces-
sary, and therefore wrong. Large hollows, in which considerable
quantities of matter have been formed; whose extent, with regard
to the intestine, is deep; and whose orifice is in the buttock, at a
distance from the anus, have always more induration about them,
and discharge a larger quantity of gleet, than those which are
smaller, more shallow, and thinner; and whose matter has burst
its way out, by an opening near to the fundament. If the former
then are curable by a mere longitudinal division of the intestine,
without excision, which Mr. De la Faye, by his prescription, in
some measure allows, (and which is a truth beyond contradiction
or contest,) surely extirpation must be unnecessary in the latter. It
can hardly be supposed, that nature will be able to do more in
cases attended with increased difficulties and impediments, than
in those where every circumstance is more favourable, every hin-
derance less. And yet, whoever cuts away a portion of the intes-
tine in the latter, and omitting, or not performing such operation
in the former, finds that they will do well without it, must reason
in that manner, and shut his eyes against conviction.

Mr. De la Faye is, indeed, sensible of the ill consequences
which such treatment produces, and has endeavoured to guard
against them as well as he can; but whoever has been so unfor-
tunate as to have been so treated, knows that all these precau-
tions arc, in general, ineffectual: his words are — " Lorsqu'on a
" coupe dans Poperation une portion considerable du bord de
" l'anus, et que les chairs commencent a rcmplir le vuide, il faut
" mettre dans Touverturc de cette partie une tente, un peu courte,
" qui en empechant le retrecissement lui conserve son diametre."
' When a considerable portion of the verge of the anus has been
: cut away in the operation, and new flesh begins to fill up the

vol. n. g z

234 A TREATISE ON THE

' void space, a short ter.t should be introduced into the part, in
' order to hinder the fundament from contracting in its diameter;'
but which it will often do, in spite of all the tents in (he world.

Mr. Le Dran, a writer and practitioner of considerable figure
in Paris, and whose works have been translated into English by
Mr. Gataker, is very particular with regard to this disease, and
the method of treating it; and is also an advocate for this exscind-
ing scheme, even more than Mr. De la Faye.

This gentleman uses the term fistula, without any regard to the
date of the disease, or any attending circumstances, except the
common and almost necessary appearances when an abscess of
this kind has been suffered to burst; viz. a small orifice, some de-
gree of induration, and a discharge of faecal matter: all which
are circumstances that necessarily accompany every abscess form-
ed in the neighbourhood of, and piercing, the rectum; and this, at
the verv first hour, full as much as at any time after. So that,
according to this manner of using the term, an abscess so circum-
stanced, and a fistula, are synonymous; which I apprehend cannot
be, without confounding together two things materially and essen-
tially different from each other. He says — " Je vois un petit trou
" a co f e de l'anus, je sens des callosiles auiour, et je vois sortir
"•par ce trou tine assez grande quantise de pus; je conclus que
" c'esl une fistule qui peut-ere interesse 1'intestin rectum. Je vois
" sortir par ce trou, un peu de matiere stercorale delayee; ou bien
" le malade me dit, qu'il en sort quelquefois; je ne doute plus
" que le boyau ne soil perce; et je dis que e'est une fistule com-
" ple.e.' - ' — ' When I see a small orifice by the side of the anus,
' and perceive a hardness round about it, and find that it dis-
4 charges a large quantity of matter, I conclude that it is a fistula,
' which most probably affects the rectum. When I find something
1 like faeces discharged from this orifice, or mixed with what is
'discharged from it, or the patient informs me that such kind of
' discharge is made, I call the disease a complete fistula.' — This
is, undoubtedly, the general custom; notwithstanding which, the
disease, in the state Mr. Le Dran has described it, may have no
one true characteristic of a fistula; nor require any of that treat-
ment which is said to be necessary and proper in such case, a
matter of great consequence to the patient.

FISTULA IN ANO. 235

In the operative part of (lie treatment of the disease, Mr. Le
Drau warmly espouses the free removal, or extirpation of parts.
" S'il ne l'est que d'un coie, il faut emporter ce qui est clenue;
" certain que si l'on le laisse, la playe restera fistuleuse; et que si
" l'on se contents de le fendre, les deux lambeaux flottaus, dans
"la playe, rendront les pansemens ties difficiles, et menie la
" playe fistuleuse." — ' If ihe disease be on one side only, all that
' part of the intestine, which is laid bare by the matter, ought to
' be cut away; because it is certain, that if such part be left in the
' wound, it will become fistulous; and that, if we only make a
' simple division, the divided lips will hang loose and floating in
' the wound, will render the application of dressings difficult,
: and make the sore fistulous.'

These are Mr. Le Dran's words and sentiments; and this the
method of practice which is taught and followed by the majority.

That some small part of this process may be necessary in the
true, old, callous, fistulous sore, I do not deny (though not even
then in any degree equal to the above direction); but that the
whole of it is absolutely unnecessary in the recent abscess, I can,
from repeated experience, venture to affirm. That mere division
of the naked intestine (if such division be dressed properly) will
not render a sinus fistulous which was not so before, is a truth as
clear as any in Euclid; and, indeed, it is to me matter of wonder
how such opinion could ever be embraced. The division of the
intestine, by laying ihe cavity of the sinus open, destroys or re-
moves the principal circumstance which can make such a case
resemble a fistula, by converting a hollow sinous ulcer into an
open one; and with regard to the other characteristic, induration,
certain it is, that if the knife does not find the parts hard, it can-
not possibly make them so; on the contrary, it puts ihem unler a
necessity of undergoing such a degree of suppuration, as, if pro-
perly managed, will prove the cure of thai very induration.

Mr. Le Dran says, " That the lips of the wound will hangfloat-
" ing, will render the dressings difficult, and the sore fistulous."
I think I understand what Mr. Le Dian means: the tumid lips of
the recently made incision will certainly be a hinderance to the
cramming in a quantity of dressings; and such attempts will, as
certainly, increase the tumefaction and hardness; and, if persisted

23$ A TREATISE ON THE

in, with the help of a little escharotic, may bid fair for producing
a callous sore; but all this lies at the door of the surgeon, and not
of the case; all this is unnecessary, improper, and pernicious. I
cannot, under such treatment as I would call good surgery, con-
ceive the tumefaction and inflamed state of the lips of the divided
gut to remain more than a few days; during which time, it must
be the business of art to appease, relax, and produce suppuration;
which, if properly executed, will infallibly prevent all tendency
towards a fistulous sore, instead of producing one.

That the lips of the wound in the rectum will not separate from
each other, in such manner as to admit a large quantity of lint;
and that the membranous structure of the part will render such
lips large, and subject to inflammation, until some degree of sup-
puration comes on, is beyond all doubt; but neither of these are
reasons for extirpation: for the inflammation will be full as high
where a piece is cut out, as where the part is merely divided, and
all the symptoms of pain and uneasiness full as great, if not
greater; and with regard to the impracticability of putting in a
quantity of dressing, I repeal, that it is not at all necessary; but
that, on the contrary, it is wrong, and tends only to mischief. A
dossil or two of fine iint should, immediately after the incision is
made, be placed between the divided lips, by passing them from
the cavity of the rectum laterally into the cavity of what before
such division was the sinus: these should not be removed, until
either the beginning suppuration, or the necessary action of the
gut in going to stool, throws them out; when their place should be
supplied with others of equal size, imbued with an easy soft di-
gestive.

If the patient be in health, the lips of this wound, like those
in all other membranous parts, after they have been crude, tumid,
and inflamed, and have for a few days discharged a thin, disco-
loured kind of gleet, will begin to suppurate: if such suppuration
be by proper, that is, by soft, gentle treatment, encouraged, not
only the tumefaction and inflammatory hardness brought on by
the incision will soon subside and disappear, but also all the in-
duration which attended the sinus before it was laid open.

On the other hand, if the patient's habit be bad, and no such
inflammatory tumefaction succeed to the incision, but instead ol

FISTULA IN ANO. 237

it tilt; lips of the wound are soft, flabby, and inclining to be livid,
the case has undoubtedly an unpromising appearance; but the re-
medy is not chirurgical. Removal of parts will not remove or
amend this state of the sore, or at all lessen the hazard arising
from it; it may indeed render the introduction of dressings some-
what more easy; but it neither will, nor can make such dressings
at all more effectual, or more conducive to the one end which
ought to be pursued.

In such case, the remedy must be an internal one; and who-
ever depends upon externals will give his patient much unneces-
sary trouble, and only waste his time.

The truth is, this doctrine of the necessity of cutting out a por-
tion of the intestine (though it is as old, or perhaps older, than
Celsus) k is almost a necessary consequence of the manner in which
these sores (upon a supposition of their being fistulous) almost al-
ways have been, and do still continue to be, generally treated. —
1 mean, the custom of cramming them full of lint, and of charging
that lint with medicines, which, though used under more gentle
appellations, are really escharotics. — Upon this plan, I am wil-
ling to allow that the lips of the divided intestine will be in the
way, and prove a considerable impediment in the introduction of
such dre: sings; and I will also allow, that by means of such me-
dicines, h? whole wound will be irritated, inflamed, and harden-
ed; and so far wear the appearance of being fistulous, as neither
to yield good matter, nor be disposed to heal; at least, not till na-
ture has got the better of the surgeon.

What Mr. Le Dran says, in another paragraph of the same
tract, may serve to strengthen what I have asserted. — " S'il est
" denue des deux cotes, il faut, pour le conserver, faire a Pautrc
" fesse une contreouverture, pres de la, et la faire assez longue
M pour pouvoir panser commodement: puis ecouter ce que la na-
" lure fera pour lui." — ' If the gut be denuded on both sides, a
c counter opening should be made on the other side, long enough

R ' In hoc genere demisso specillo, daubus lineis incidenda cutis est, ut
' media inter eas babenula tenuis admodum injieiatur, ne protinus ora coeant,
'sitque locus aliquis linimentis, qua: quart) paucissima superinjicienda sunt,
• omniaque codem modo facienda, quse in abscessibus nosita sunt.

Cm

,238 A TREATISE ON THE

' to permit, conveniently, the application of dressings; and then
' we should wait, and see what nature will do toward assisting the
' patient.'

A very important piece of advice this; worth all the directions
for the extirpation of parts; and which, if timely and duly attend-
ed to, will, generally, render all such directions quite unneces-
sary.

It is, indeed, somewhat remarkable, that the same gentleman
should give the above very excellent advice, and, almost in the
same breath, add what follows. — " S'il est denue exactement
" dans toutc sa circonference, et que son depouillement ne s'etend
" pas plus haut que les releveurs de l'anus, il faut emporter tout
u ce qui est denue." — ' If the intestine be bared by the matter all
• round, and this denudation does not extend above the levatores
' ani, all that part which is so bared, should be extirpated.' That
is, the whole verge of the anus; all that part which is so formed
by nature, as by its relaxation to permit the largest and most solid
stool to pass out; and by its constriction, to detain and keep in,
for a while, the most fluid, sharp, and stimulating one; all that
part which, when destroyed or removed, not only never can be
renewed, but never can have its place supplied, nor its office pro-
perly executed, by what must succeed to it: surely it may, with
great justice, be said, that the latter condition of a man in these
circumstances is worse than the former; and that his remedy
proves a most afflicting disease. 1

1 In the Memoirs of the French Academy, is a case of this kind, related by
Mr. Faget. The patient had an abscess on each side of the rectum ; which,
before Mr. Faget saw it, had been opened without meddling with the gut.

The two abscesses communicated by a hollow or sinus under the os coccy-
gis ; the depth in all the upper part is described to be about two inches, but
in the perineum the skin only was separated ; that is, the hollow was quite
superficial. After five months' attendance, during which time the rectum
was never divided, the patient was brought to Paris ; where, in a consulta-
•tion between the Messieurs Faget and Boudon, it was agreed, that the only
method of obtaining a cure must be by extirpating, or cutting away, the whole
extremity of the intestine, as deep as it was laid bare ; which operation is thus
described — " Je percai d'abord le rectum de droit a gauche, avec tin gros
" stilet; avec lequel je fis l'anse. Je commences a couper le lambeau de
" pcau qui tenoit au coccyx, et je continual tout le long d'attache des mus-
■' Hes releveurs j'isqu' «. la parte moyenne du perin^e, ou i! y avolt beau-

FISTULA IN ANO. 239

Prejudice often prevents us from seeing truth, though it stands
before us; for Mr. Le Dran, though he so strongly recommends
the extirpation of a portion of the intestine, yet lias made the
same observation on those fistulas, which run too high for extirpa-
tion, as Mr. De la Faye. He has very justly remarked, that they
will do well without such operation; and has given so good and so
true an account of the matter, that it is amazing he should not see
that the same method, both of reasoning and of acting, was equal-
ly applicable to both cases; that is, to those fistulas which do not
extend so high, as well as to those which do. He says — " On
M trouve souvent des sinus qui montent fort haut le long du rec-
" turn; et meme vers la vessie, dans la lissu cellulaire qui entoure
" ces parties: sinus qui semblent devoir rendre ces maladies in-
" curables, parcequ'ils vont plus haut que le doigt ne peut aller.
" Mais l'experience m'appris que ces sinus se remplisserent pres-
" que toujours dans les six premiers jours — ou, pour parler plus
" justement, que les chairs se rapprocherent, n'ayant etes qu'
" ecartes par les pus, et non fondues." — ' Sometimes we meet
' with sinuses, which run so high in the tela cellulosa, along the
' rectum, and up toward the bh. icier, that one would be inclined
' to believe them to be incurable, from their being beyond the
' reach of the finger;" 1 but I have learned from experience, that

" coup de duret£, et de callosite, que j'cmportai ; je pans:<i la playe avcc un
" gros bourdonnet, et des lambeaux de linge trem pes dans I'eau alumineuse,
" le tout soutenu par plusieurs compresses et un bandage convenable." &.c.
Mr. Paget says, that the patient was six months longer in getting well. To
which 1 must take the liberty of adding, that he was much more fortunate
than some whom I have seen under the same treatment. The relator, in the
rest of the memoir, endeavours to explain the method by which the new anus
became capable of executing the office of the old one ; and very justly seems
to wonder, why the surgeon, who first had the care of the patient, and who
first opened the abscesses, did not divide the rectum in each of them. Mr.
Faget's surprise, and his censure on the operator, are certainly well founded
but I must own that it seems to me to be full as extraordinary, that he who
saw the propriety of its having been done before, should not, at least, try what
it would do afterward. If this experiment had been made, and the case pro-
perly conducted, I make little doubt that the patient might have been cured
without the loss of his fundament — a loss, which, though possibly in youth
and health he might not be so sensible of as to alarm him, yet in age, or a state
of debility, must prove a very grievous one.
■ It is hardly decent for a surgeon to say it ; but I am much inclined to

240 A TREATISE OK THE

c these sinuses fill up within the first six days— or, to speak more
« properly, that the membranes, which have been only separated,
' and not dissolved by the matter, again approach each other.' —

believe that this circumstance of the sinus being out of the reach of the fin-
ger is the very individual one on which the expedition of the cure (that is,
the shortness of the time in which Mr. Le Dran says that he finds these cavi-
ties filled up) depends. For, if they were within the reach of the finger of
an operator who thinks as this gentleman writes, he would immediately go to
work with his instruments; and if he did nothing worse, must necessarily
prolong. — It has always been a very generally received opinion, that if the
hollow of the sinus be higher than a finger in ano can reach, all chirurgic
operation is fruitless. There is hardly an author ancient or modern who
has not inculcated this doctrine, though daily experience might have con-
vinced them of its falsehood.

Among the rest Heister has given us his opinion on this subject, in the
most positive manner: — " Et sane nisi digitus, in anum depressus, fistule os
" attingere valet, verum illud adhuc profundius latet, sine vite periculo, ob
" metum ledendarum venarum majorum, sectio institui nequit; adeoque tunc
" parum plerumquc, imo vero nihil omnino chirurgi artificia proficiunt," 8cc.

This, which, as I have observed before, is the doctrine of all our writers,
has always stood upon the same principle ; viz. the fear of hemorrhage ; and
all the propagators of it have always supposed, that nothing but a division of
the whole sinus could possibly product a cure ; which supposition is by no
means true.

When the case is an abscess formed in the cellular membrane, the length
of the sinus must be proportioned to the distance of the seat of such abscess
from its external orifice: this is sometimes considerable, quite out of the
reach of the finger in ano, but it does by no means follow, that either this si-
nus must be divided through its whole length, or that the disease cannot be
cured ; and therefore it is better not to meddle with it at all. Frequent ex-
perience proves the contrary. If all that part of it which is within the reach
of the finger in ano (that is, all that part of it which is principally affected by
the action of the muscles of the anus and rectum) be fairly divided ; if the
wound so mr.Je be dressed in such manner as to produce no inflammatory ir-
ritation; if it be not frequently poked into, and examined; and the patient's
habit be properly taken care of, the length of the sinus will add very little
to the difficulty attending the cure ; all that is out of reach will collapse and
heal ; and the case will very soon be exactly the same, as if the whole hollow
was within the finger's length.

The probability of an hemorrhage from the large vessels about the upper
part of the rectum, is a thing which ought by all means to be avoided, as it
inight give a great deal of trouble, and create some hazard ; but the opera-
tion which would induce such apprehension being quite unnecessary, this
risk is out of the question.

The last mentioned author, (Heister,) although in general a very exact

FISTULA IN A3S0.

Can any man give a more rational or more (rue account of this
matter, or produce a stronger argument against cutting out a part
of the intestine? The operator's finger cannot reach the upper
part of the sinus, and therefore he cannot extirpate; but sinuses,
which by being out of reach cannot be extirpated, do well with-
out it, merely by the help of nature; who, when the matter is dis-
charged, and such an opening made as prevents any future lodge-
ment, brings the sides of the cavity together, and endeavours
thereby to obliterate it. It is true that she can but seldom ac-
complish this end entirely; I mean, throughout the whole length
of the sinus; the lower part generally remaining open, though con-
tracted to narrow compass: this it is most frequently absolutely
uecessary to divide, in order to obtain a cure; but that part of the
said sinus (if there be any) which is out of the reach of the in-
strument guided by the finger in ano, is not a matter of that con-
sequence which it is supposed to be. If the ower part, or what
is fairly within reach, be divided, such division will, in most cases
which are curable at all, be fully sufficient for a cure, as I have
often and often experienced. I know that this is contrary to the
generally received doctrine, but I know it is true; and am much
inclined to believe, that the supposition of the necessity- of laying
open the whole sinus, however deep it may run, has contributed
greatly to the fatigue and hazard which many people have unne-
cessarily undergone in this disease; it has occasioned such poking
with long probes, and such cramming in of tents and dressings, as
have proved extremely pernicious;jmd brought on symptoms and
trouble, which w.ould not have attended the same cases under
other management.

One word more, and I have done with this part of my subject.

and careful writer, seems, in his observations on this complaint, rather to
copied what our predecessors have written on it, than to have given us
what his own experience migh,t have furnished him with : the latter would
have convinced him, that all his preparation by bleeding, purging-, &c. befor^
the operation, is quite unnecessary ; that the blind fistula are very little, if
il all, more difficult of cure than the open ones ; and that the disease in ques-
tion admits of being- treated and cured in pregnant women, as perfectly and
as easily as in those who are not so. The contrary doctrines are certainly
no rules of good practice, however venerable tli from their anti-

quity.

VOL. II. H ' J

^42 A TREATISE ON THE

As I have given my opinion so freely concerning the practice oi
excision, a representation of the inconveniences likciy to arise
from ii, might from me be thought to be an exaggeration; I shall,
therefore, take the liberty once more to quote Mr. Le Dran; who,
considered as a patron of the practice, cannot be supposed to over-
charge it. He says, " Cette grancle playe sera dans les commence-
' mens pansee comme les airtres; mais quand les chairs com-
"' mencent a se rapprocher, elle demande des attentions particu-
" lieres; sans lesquelles, 1'anus deviendroit si etroit que les
" excremens ne pourroient y passer; pour pen qu'ils ont de con-
" sistence. II faut done alorsmettre jusque dans le rectum unc
w tente de linge, lisse, assezlongue, et assez grosse, pour enlretenir
"• le passage. II faut meme sur le fin, supplier a cette tente, par
" une espece de suppositoire d'yvoire, perce en forme de cannule ;
" et avoir soin de ia bien assujetir par la bandage, a fin qu'elle nc
" sorte pas. La cicatrice etant faite, il faudra que le malade porte
" cette suppositoire encore pres d'un an; sans quoi la cicatrice
" serreroit l'anus de plus en plus." — ' This large wound should, at
' the first, be dressed like any other; but when the sides begin to
' approach each other, it will then demand particular attention,
' lest the fundament should become so contracted, that the fasces.
' if they be at all hard, cannot be expelled. Therefore, in order
' to keep the passage of a proper size, a smooth tent made of linen
' should be introduced; which tent should be of such a size and
' length, as to serve the purpose for which it is intended. Toward
* the close of the cure, in the place of this, an ivory suppository,
' made in the form of a cannula, must be substituted, and kept
c constantly in, by means of a proper bandage. Which supposi-
' torv must be worn for near a year after the sore is perfectly
4 healed; otherwise the cicatrix will contract the anus still more
' and more every day." 1

This is what is called cutting for a fistula: this is the operation
which they who have undergone it do so pathetically describe and
lament, and what they, who have the misfortune to be afflicted

n To which he might have added, that when all this is done, and every pre-
cautioi of this kind used, the patient will always find it difficult and painful,
and sometimes absolutely impossible, to retain a loose stool — an evil stil!
greater than the trouble of expelling a hard one.

FISTULA IN ANO, 24$

with the disease, do (from the account of others) so fearfully dread.
It is true, that it has the sanction of several eminent writers; that
it is practiced by many surgeons; and that it is recommended and
exhibited by anatomico-chirurgical teachers; but notwithstanding
these authorities, I shall not scruple to say, that it is cruel,
unnecessary, and wrong.

That by these means abscesses juxta anum, and fistula? in ano,
(as they are called,) are cured, I make no doubt; nay, I know that
they are; but I also know, from repeated experience, that they are
curable by means which are more expeditious, more easy, and nei-
ther hazardous in the use, nor productive of evil in the event. I
mean by mere simple division of all that part of the sinus which
is within reach; by soft, gentle treatment of the sore after such
operation; and by proper care of the habit.

The haemorrhage (to say nothing of the pain) which now and
then attends the extirpation of a large piece of the intestine and
fundament, is alarming both to weak minds and to weak bodies:
and the inconveniences arising from loss of substance about the

° When the habit is out of order, as it most frequently is in persons afflicted
with this disorder, if recourse be not had to internals, the surgeon will gain
little ground. This is a circumstance which ought always to be attended to ;
and it is in some measure owing to a want of due regard to it, that we find
such a farrago of different dressings ; such remedies for fungous, for foul, for
callous sores, &c. These diseased appearances and circumstances most fre-
quently proceeded from disorders in the habit; and if that be not corrected,
the same appearances will continue, notwithstanding all our escharotics,
detergents, digestives, incarnatives, &c. &c. &c.

In cold, debauched, lax, or sluggish habits, if the patient be not warmed
by aromatics, and braced by the bark, these cases will often prove tedious
and troublesome.

From the induration of the parts about, from the face and colour of the
sore, and from the discoloured gleety discharge, callosity, latent mischief,
and undiscovered sinuses, will be suspected ; whereas, in truth, neither one
nor the other are the cause of such diseased appearances. The administration
of proper remedies will, most commonly, in a few days, produce such an
alteration, as the whole art of surgery could not (by mere externals) bring
about in as many weeks, if at all. Many and many a sore of this kind have I
seen brought into the hospital, which has had all these disagreeable appear-
ances, which has long and fruitlessly been ;rcated with all the variety of
externals, and which a decoction of the bark and rad. serpentariae has, in a.
very short time, put into such a condition as to want only dry lint

244 A TREATISE ON THE

verge of the anus, either in strong exercise, in the retention oi
loose stools, or the expulsion of hard ones, are so great, that I have
known several people who have daily and sincerely wished for
their uncut fistula? again; and who, either from pain or unclcanli-
ness, or both, have been rendered truly unhappy.

In short, I can venture to assert, from many years' experience
on a great variety of subjects, that when the disease is curable by
chirurgic art, the method which I have proposed, will, with more
ease, expedition, and certainty, attain that end, than the method of
extirpation; and that without producing any of those very disa-
greeable circumstances which Mr. Le Dran has so justly described.

And for the (ruth of this assertion, I appeal to all those (many
in number) who have, for these ten or twelve years past, attended
St. Bartholomew's hospital.

SECT. VI.

Hitherto I have considered the disease either as an abscess
from which the matter has been let out by an incision, made by a
surgeon, or from which the contents have been discharged by one
single orifice, formed by the bursting of the skin somewhere about
the fundament. I am now to take notice of it, when instead of
one such opening there are several.

This state of the case generally happens when the quantity of
matter collected has been large, the inflammation of considerable
extent, the adipose membrane very sloughy, and the skin worn very
thin before it burst. It is, indeed, a circumstance of no real con-
sequence at all; but, from being misunderstood, or not properly
attended to, is made one of additional terror to the patient, and ad-
ditional alarm to the inexperienced practitioner; for it is taught,
and frequently believed, that each of these orifices is an outlet
from, or leads to, a distinct sinus or hollow; whereas, in truth, the
case is most commonly quite otherwise: all these openings are
only so many distinct burstings of the skin covering the matter;

FISTULA IN AN0. 245

and do all, be they few or many, lead and open immediately into
the -one single cavity of the abscess; they neither indicate, nor
lead to, nor are caused by, distinct sinuses; nor would the appear-
ance of twenty of them (if possible) necessarily imply more than
one general hollow.

if this account be a true one, it will follow, that the chirurgic
treatment of this kind of case ought to be very little, if at all, dif-
ferent from that of the preceding; and that all that can be neces-
sary to be done, must be to divide each of these orifices in such
manner as to make one cavity of the whole. This the probe-
knife will easily and expeditiously do; and when that is done, if
the sore, or more properly its edges, should make a very ragged,
uneven appearance, the removal of a small portion of such irregu-
lar angular parts will answer'all the purposes of making room fou»
the application of dressings, and for producing a smooth even ci-
catrix after the sore shall be healed.

When a considerable quantity of matter has been recently let
out, and the internal parts are not only in a crude, undigested state,
but have not yet had lime to collapse, and approach each other,
the inside of such cavity will appear large; and if a probe be push-
ed with any degree of force, it will pass in more than one direc-
tion into the cellular membrane, by the side of the rectum. But
let not the unexperienced practioner be alarmed at this, and imme-
diately fancy that there are so many distinct sinuses; neither let
him, if he be of a more hardy disposition, go to work immediately
with his director, knife, or scissors; let him enlarge the external
wound by making his incision freely; let him lay all the separate
orifices open into that cavity; let him divide the intestine length-
wise by means of his finger in ano; let him dress lightly and easi-
ly; let him pay proper attention to the habit of the patient; and
wait and see what a few days, under such conduct, will produce.
By this he will frequently find, that the large cavity of the abscess
will become small and clean; that the induration round about will
gradually lessen; that the probe will not pass in that manner into
the cellular membrane; and consequently, that his fears of a multi-
plicity of sinuses were groundless. On the contrary, if the sore
be crammed or dressed with irritating or escharotic medicines, all
the appearances will be different; the hardness will increase, the

246 A TREATISE ON THE

lips of the w,ound will be inverted; the cavity of the sore will re-
main large, crude, and foul; the discharge will be thin, gleety,
and discoloured; the patient will be uneasy and feverish; and, if
no new cavities are formed by the irritation of parts, and confine-
ment of matter, yet the original one will have no opportunity of
contracting itself; and may, very possibly, become truly fistulous.

I will not say that there never is more than one sinus running
along the side of the intestine (I mean on the same side); but I
will venture to assert, that for one instance in which the case is
really so, forty are supposed and talked of. Distinct and separate
openings in the skin, from the same cavity or sinus, are common;
but perfectly distinct sinuses, running along the intestine on the
same side, are very far from being so: they are very uncom-
mon.

I should be sorry to have such a misconstruction put upon what
I have said, as to have it supposed that I made light of a disease
which every body knows is sometimes attended with very trouble-
some circumstances; or that I moke pretension to any particular
secret method of treating it; or that I think myself more capable
©f conducting it than the generality of practitioners: as none of
these are true, I should be sorry to have them imputed to me. I
do allow (what is undoubt. diy true) that this disease, in some con-
stitutions, and under some circumstances, will engage the attention,
and exercise the judgment, of the best and most able practitioner;
but, on the other hand, I must repeat, that a great deal of the
trouble which it is sometimes attended with, does not arise from
the disease itself, but from misconception, and improper treatment.

I have freely, and without reserve, related that method of treat-
ment which I have found to be most successful; nor do I know
any applications which are at all specifice, or more' pro per for
this kind of sore than for all others, in par's of the same structure:
the most simple, and they which give least pain, are the best.
.Neither these nor mere dry lint, should ever be introduced in
larger quantity than can be admitted and borne with ease; that
the sore may not be distended, but a fair opportunity given to na-
ture to contract it gradually.

This every practitioner may be capable of executing, since it
consists more in abstaining from doing mischief, than in doing

FISTULA IN ANO. 247

any thing which may require particular judgment or dexterity. It
is true, that the method which I have proposed will considerably
lessen the chirurgic apparatus of instruments and dressings; but
it will be attended with success, and produce that which every
patient has a right to expect from his surgeon — a firm cure in a
short space of time, and with the least possible fatigue.

It sometimes happens, that the matter of an abscess, formed
juxta anum, instead of making its way out through the skin, ex-
ternally near the verge of the anus, or in the buttock, pierces
through the intestine only. This is what is called a blind internal
fistula — -fistule borgne interne.

In this case, after the discharge has been made, the greater part
of the tumefaction subsides, and the patient becomes easier. If
this does not produce a cure, which sometimes, though very sel-
dom, happens, some small degree of induration generally remains
in the place where the original tumor was. Upon pressure on
this hardness, a small discharge of matter is frequently made per
anum; and sometimes the expulsion of air from the cavity of the
abscess into that of the intestine may very palpably be felt, and
clearly heard: the stools, particularly if hard, and requiring force
to be expelled, are sometimes smeared with matter; and although
the patient, by the bursting of the abscess, is relieved from the
acute pain which the collection occasioned, yet he is seldom per-
fectly free from a dull kind of uneasiness, especially if he sits for
any considerable length of time in one posture. The real differ-
ence between this kind of case, and that in which there is an ex-
ternal opening (with regard to method of cure) is very immate-
rial; for an external opening must be made, and then all difference
ecases. In this, as in the former, no cure can reasonably be ex-
pected, until the cavity of the abscess, and that of the rectum,
are made one; and the only difference is, that in the one case we
have an orifice at, or near the verge of the anus, by which we ere
immediately enabled to perform that necessary operation; in the
other we must make one.

Some of the best of the modern writers have, I think, repre-
sented this state of the disease in such manner as to make it seem
to labour under difficulties, which I cannot say that I ever found

24S A TREATISE ON THE

it really did; and have thereby thrown the appearance of obscurity
and double on what is generally clear and easy.

In Mr. De la F aye's very excellent notes on Dionis, is the fol-
lowing passage. " Lorsque les fistules n'ont pas d'ouverture ex-
" (erne, ct que lien ne designe le lieu ou il faut faire ['operation,
" il y n deux moyens de le decouvrir. Le premier est de l'inven-
" tion de feu Mr. Thibaut, qui portoit le doigt index dans l'anus,
" et le recourboit; ensuite, en le tirant an peu a lui, pour ramener
" a 1'exterieur le foyer de la matiere, tandis qu'il pressoit avec
" un autre doigt les environs du fondement, la douleur qu'il cau-
" soit au malade marquoit le lieu ou il falloit faire l'incision pour
" rendre la fistule complete. Le second est de Mr. Petit, qui
" met dans l'anus pendant vingt-quatre heures une tente, qui
" touchant l'ouverture de la fistule, empeche le pus de s'e'eouler,
" et le ramasse en assez grande quantise pour faire a I'exterieur
" une tumeur, qu' indique le lieu ou il faut faire l'operation.''
c When fistulas have no external opening, and there is no mark
'• whereby to distinguish the place where the operation ought to
' be performed, there are two methods of discovering it; the first
' is that of the late Mr. Thibaut, who put his fore-finger into the
{ rectum; and curving it endeavoured to bring the foyer (that is,
1 the hollow which furnishes the matter,) nearer to the external
' part of the fundament; while, with his other finger, he pressed all
1 the parts round about: the pain which he, by these means, gave
' to the patient, marked out the place where the incision ought to
' be made, in order to render the fistula complete. The second
' method is that of Mr. Petit: he put into the anus, for the space
' of twenty-four hours, a tent; which, by stopping up the orifice of
1 the fistula, hindered the matter from running out into the cavity
c of the gut; and forced it to be collected in such quantity, as to
' form an external tumefaction, sufficient to indicate the place
* where the operation ought to be performed.'

The former of these, as far as it depends on that single circum-
stance, that the point where the pain is felt is the exact place where
the opening ought to be made, is, by no means, to be depended
upon: the latter method is operose, troublesome, and, in general,
very insufficient for the purpose. If the orifice, through which the
matter has made its way, lies high in the intestine, a tent cannot.

FISTULA IN ANO. 249

be introduced so as to press against it sufficiently, unless it be so
long, and so large, as to occupy the whole cavity of the gut. How
fatiguing, and how difficult, the retention of this, for twenty-four
hours, must be to many people, is easy to imagine: if the orifice
be near to the fundament, in the lower part of the intestine, the
possibility of closing it may be somewhat greater; but the incon-
venience must be nearly the same, as well as the uncertainty.

In short, not to enter further into this totally unnecessary kind
of practice, I would advise the man, who thinks to try it, to con-
sider the stricture made by the contraction of the verge of the
anus; the expansion of the cavity of the gut, immediately above
that stricture; the great dilatability of the membranes of the intes-
tine; and the uneven, wrinkled state in which it must necessarily
be; and then to reflect, how very unlikely it is, that he ihould,
without filling the whole cavity, stop or block up a small breach,
whose exact situation he cannot know or learn.

It is true, that by discharge of the matter into the cavity of the
intestine, the fluctuation of it within the abcess is no more to be
felt; the tension ceases; the tumor, in great measure, subsides;
and, consequently, all these indications of its situation disappear:
but I do not remember ever to have seen a single case of this kind,
in which there was not in the buttock, or near to the verge of the
anus, either a remaining discoloration of the skin, or a hardness,
or something by which the finger of a careful, judicious examiner,
could clearly and certainly find where the disease was. Each of
the circumstances just mentioned do as certainly point out where
the hollow leading to the sinus is, as the fluctuation of the matter
did before the cavity burst; and a knife, or lancet, plunged into
this (provided it be pushed deep enough), will never fail to enter
the said hollow. When this is done, the case becomes what is
commonly called complete, and must be treated accordingly.

vol. ir. i i

250 A TREATISE ON THE

SECT. VII.

I coiME now to that state of the disease, which may truly and
properly be called fistulous. This is generally defined, sinus an-
gustus, callosus, profundus; acri sanie diffluens; or, as Dionis
translates it, " Un ulcere profond, et caverneux, dont Pentrce
" est etroite, et le fond plus large; avec issue d'un pus acre et vi-
" rulent; et accompagne de callosites."

Various causes may produce or concur in producing such a state
of the parts concerned as will constitute a fistula, in the proper
sense of the word; that is, a deep, hollow sore, or sinus, all parts
of which are so hardened, or so diseased, as to be absolutely inca-
pable of being healed while in that state; and from which a fre-
quent or daily discharge is made, of a thin, discoloured sanies, or
fluid.

These I shall take the liberty of dividing into two classes; viz.
those which are the effect of neglect, distempered habit, or of bad
management, and which may be called, without any great impro-
priety, local diseases; and those which are the consequence of dis-
orders, whose origin and seat are not in the immediate sinus or fistu-
la, but in parts more or less distant, and which, therefore, are not
local complaints.

The natures and characters of these are obviously different by
description; but they are still more so in their most frequent
event; the former being generally curable by proper treatment, the
latter frequently not so by any means whatever.

Under the former, I reckon all such cases as were originally
mere collections of matter within the coats of the intestine rectum,
or in the cellular membrane surrounding the said gut; but which,
by being long neglected, grossly managed, or by happening in
habits which were disordered, and for which disorders no proper
remedies were administered, suffer such alteration, and get into such
state, as to deserve the appellation of fistula?.

FISTULA IN ANO. 251

Under the latter are comprised all those cases in which the
disease has its origin and first state in the higher and more distant
parts of the pelvis, about the os sacrum, lower vertebras of the
loins and parts adjacent thereto; and are either strumous or the
consequence of long and much distempered habits; or the effect
of, or combined with, other distempers, local or general; such as
a diseased neck of the bladder, or prostate gland, or urethra; the
lues venerea, cancers, &c. &c.

Among the very low people, who are brought into hospitals,
we frequently meet with cases of the former kind; cases which,
at first, were mere simple abcesses, but which, from uncleanliness,
from intemperance, negligence, and distempered constitutions, be-
come such kind of sores as may be called fistulous.

In these the art of surgery is undoubtedly, in some measure,
and at some time, necessary; but it very seldom is the first or
principal fountain from whence relief is to be sought: the general
effects of intemperance, debauchery, and diseases of the habit,
are first to be corrected and removed, before surgery can with
propriety, or with reasonable prospect of advantage, be made use
of. If the patient be infected with the lues venerea, that must
first be cured; if he be anasarcous, or leucophlegmatic, that in-
disposition must be corrected; if he be feverish, that heat must be
calmed; and if he labour under any of the general ill effects aris-
ing from foul skin, dirty clothing, unclean and unwholesome lod-
ging, &c. producing pallid countenance, undue secretions, loss of
appetite, cedematous legs, intermitting fevers, &c. the state of
blood which always accompanies such complaints must be amend-
ed before surgery can be administered to any good purpose. If
knife, caustic, or whatever other external means are thought pro-
per to be used, be -applied before such general evils have been
corrected, they will do little or no good; and may do much mis-
chief. On the contrary, when the lues is corrected; when the pa-
tient is cool and gets good sleep; when the secretion of urine is
so re-established, the general absorbent faculty so restored, and
the solids s» braced, that the legs cease to swell; and the patient
recovers his natural appetite and complexion; we find the local
disease, instead of standing still, has almost always made great

252 A TREATISE ON THE

advances towards being cured, by being altered in all the principal
circumstances of induration, crudity, gleet, &c. Whatever chi-
rurgic operation or treatment may now be necessary, will in all
probability succeed immediately; whereas, all our attempts before
such care do and must prove fruitless.

The surgery required in these cases consists in laying open and
dividing the sinus, or sinuses, in such manner that there may be
no possible lodgement for matter, and that such cavities may be
fairly opened lengthwise into that of the intestine rectum: if the
internal parts of these hollows are hard, and do not yield good
matter, which is sometimes the case, more especially where at-
tempts have been made to cure by injecting astringent liquors,
such parts should be lightly scratched or scarified with the point
of a knife or lancet, but not dressed with escharotics; and if,
either from the multiplicity of external orifices, or from the loose,
flabby, hardened, or inverted state of the lips and edges of the
wound near to the fundament, it seems very improbable that they
can be got into such a state as to heal smooth and even, such por-
tion of them should be cut off as may just serve that purpose.
The dressings should be soft, easy, and light; and the whole
intent of them to produce such suppuration as may soften the parts,
and may bring them into a state fit for healing.

If a loose, fungous kind of flesh has taken possession of the
inside of the sinus, (a thing much talked of, and very seldom met
with,) a slight touch of the lunar caustic will reduce it sooner,
and with better effect on the sore, than any other escharotic what-
ever.

The method and medicines by which the habit of the patient
was corrected, must be continued (at least in some degree) through
the whole cure; and all those excesses and irregularities, which
may have contributed to injure it, must be avoided.

By these means, cases which at first have a most disagreeable
and formidable aspect, are frequently brought into such state, as
to give very little trouble in the healing.

More trouble must be supposed to attend this kind of case, than
does a mere simple, recent abscess; and more time will necessa-
rily be required to bring the parts into a kindly state; but under
proper conduct, they will in general be found to do well, without

FISTULA IN ANO. 253

any of those operations, which mankind have such dread of, and
which are in general taught and practised.

If the bad state of the sore arises merely from the improper
manner in which it may have been treated; I mean, from its
having been crammed, irritated, and eroded; the method of obtain-
ing relief is so obvious, as hardly to need recital.

A patient who has been so treated, has generally some degree
of fever, has a pulse which is too hard and too quick, is thirsty,
and does not get his due quantity of natural rest. A sore which
has been so dressed, has generally a considerable degree of inflam-
matory hardness round about; the lips and edges of it are tumid,
full, inflamed, and sometimes inverted; the whole verge of the
anus is swollen; the hemorrhoidal vessels are loaded; the discharge
from the sore is large, thin, and discoloured; and all the lower
part of the rectum participates of the inflammatory irritation, pro-
ducing pain, bearing down, tenesmus, &c. Contraria contrariis is
never more true than in this instance: the painful, uneasy state of
the sore and of the rectum, is the great cause of all the mischief,
both general and particular; and the first intention must be to alter
that. All escharotics must be thrown out, and disused; and, in lieu
of them, a soft digestive should be substituted, in such manner as
not to cause any distention, or to give any uneasiness from quantity;
over which a poultice should be applied: these dressings should
be renewed twice a day; and the patient should be enjoined abso-
lute rest. At the same time, attention should be paid to the general
disturbance, which the former treatment may have created. Blood
should be drawn off from the sanguine; the feverish heat should
be calmed by proper medicines; the languid and low should be
assisted with the bark and cordials; and ease in the part must, at
all events, be obtained by the injection of anodyne clysters of starch
and opium.

If the sinus has not yet been laid open, and the bad state of
parts is occasioned by the introduction of tents imbued with escha-
rotics, or by the injection of astringent liquors, (the one for the
destruction of callosity, the other for the drying up gleet and hu-
midity,) no operation of any kind should be attempted until both the
patient and the parts are easy, cool, and quiet: cataplasm, clysters,
rest, and proper medicines must procure this; and when that is

254 A TREATISE ON THE

accomplished, the operation of dividing the sinus, and (if neces-
sary) of removing a small portion of the ragged edges, may be exe-
cuted, and will, in all probability, be attended with success. On
the contrary, if such operation be performed while the parts are
in a state of inflammation, the pain will be great, the sore for several
days very troublesome, and the cure prolonged or retarded, instead
of being expedited.

Particular individual cases may require little particularities in
the treatment; but what I have drawn is the general outline. In this,
as in most parts of physic and surgery, the first and great object is,
to know what the intention is which ought to be pursued: when
that is clear and determined, a man of any degree of knowledge
will seldom be at a loss for materials wherewith to execute it.

Abscesses, and collections of diseased fluids, are frequently
formed about the lumbal vertebrae, under the psoas muscle, and
near to the os sacrum; in which cases, the said bones are some-
times carious, or otherwise diseased. These sometimes form
sinuses, which run down by the side of the rectum, and burst
near to the fundament.

The discharge from these is generally large, fetid, thin, and
sharp: it is therefore no wonder that the sinuses by which they
are made, together with the orifices thereof, become hard and
callous; that is, truly fistulous. But it must be obvious to every
one who will consider it, that the chirurgic treatment of these sores
and sinuses can be of very little consequence towards curing the
diseases from whence they arise: their seat is generally out of the
reach either of our instruments or our applications; and their
nature is not frequently found to be capable of being altered by
medicine. However that may be, certain it is, that what advan-
tage a person in such circumstances is at all likely to receive, is
not derivable from surgery, but must be from medicine, or from
more powerful nature.

Persons who have long laboured under what is commonly call-
ed a cachectic habit, have sometimes large collections of matter
formed in the cellular membrane within the cavity of the pelvis,
(which, like the preceding, form sinuses,) and burst their way
out near the anus. These sinuses, from the nature of the dis-
charge, from the depth of the seat of the disease, and from the

FISTULA IN ANO. **KJ

length of time which the drain continues, do almost necessarily
become fistulous. Such collections do sometimes prove salutary
crises; though much more frequently they hasten the patient's
dissolution: but be the event which it may, although the sore is
certainly fistulous, yet can the art of surgery do very little, if any,
material service. If the event be good, the crisis must be far ad-
vanced, and very nearly determined, before any operation, or
even dressing (except what is superficial, and merely for the pur-
pose of cleanliness,) can be of any use; and if the discharge
proves too much for the strength of the patient, it is pretty clear,
that neither the art of surgery, nor indeed any other, can avail
him.

On the other hand, if it so happens, that nature is so powerful,
that, by means of this drain, she can free the habit from its former
diseased state, or if, by the help of medicine, such alteration can
be brought about, the fistula will not prove very troublesome; for
the same alteration, at least in some degree, will be found to have
been made in that; and if it be not brought thereby absolutely
into a healing state, yet it will be found to be so much altered in
its principal circumstances, that the common method, already laid
down, will be fully sufficient for the completion of a cure.

We are, by authors, very frequently advised not to be too hasty
in the cure of these cases; as the continuance of the discharge
may prove beneficial to the patient. That these discharges are
now and then of great advantage, is beyond all doubt; but very
happily for such patients, the healing or not healing these sores is
very seldom within our determination. We may, indeed, (and I
fear often do,) by indiscreet conduct, prevent a sore from healing
when it is nature's intention that it should be healed; but when
she finds herself relieved, or benefited by a discharge of this kind,
she will generally continue it, in spite of our most officious en-
deavours to the contrary.

Cancers and cancerous sores are sometimes formed in the ca-
vity, or in the neighbourhood of the rectum and fundament; in
which they make most terrible havoc, and afford most melancholy
spectacles.

As I do not know what will cure a cancer, I leave the discus-
sion of this to those'who sav that they do: most sincerely wishing,

25G A TREATISE ON THE, &C.

that it was in my power-to say, that I had, once in my life, known
them to have fulfilled their promise.

Fistulous sores, sinuses, and induration about the anus, which
are consequences of diseases of the neck of the bladder and ure-
thra, called fistulae in perineo, require separate and particular
consideration.

In these, the external openings, with the sinuses leading from
them into the cellular membrane, are the least part of the com-
plaint: the stricture in the urethra, the induration of the whole
neck of the bladder, the hardened, fungous, enlarged, or ulce-
rated state of the prostate gland, the diseases of the verumonta-
num, of the vesiculae seininales, and vasa deferentia, are the great
and principal objects of consideration.

A very serious consideration they certainly make. Great and
manifold are the miseries which are derived to mankind from
these causes; and much more diligent inquiry do they deserve,
than they have yet met with: but as they do not immediately be-
long to my present subject, I must omit, or, at least, to another
opportunity defer, entering into them. ,

IlELATIVE TO

THE CATARACT, THE POLYPUS OF THE NOSE,
THE CANCER, OF THE SCROTUM,

MORTIFICATION OF THE TOES AND FEET.

VOL. II.

*k

PREFACE.

THE first of the following tracts contains some remarks on a
disease, to which persons of every rank and condition are liable:
and by which they are rendered truly unhappy.

From an unpardonable indolence, or an equally blamable timi-
dity, it has been too much the custom, in this country, to leave
the management of this complaint to pretenders and itinerants,
some of whom have been, in some degree, acquainted with the or-
gan and its diseases, others most grossly ignorant of both; conse-
quently the benefits and the misfortunes which have attended their
undertakings have been various. With these I have nothing to
do; but cannot help taking the liberty to observe, that until the
profession in general have made themselves capable of being es-
sentially serviceable to mankind in thfs point, they must not be
surprised that the unfortunate and unknowing give credit to fair
promises.

What I shall, in the following pages, advance, regarding the
cataract, is not the consequence of a mere desire to write, but
arises from a conviction founded on frequently repeated expe-
rience, that we have, within a few years past, reprobated an ope-
ration which, in proper hands, is capable of producing great good;
and have substituted in its place another, which, though perhaps
right and useful in some particular instances, has, by being too
generally practised, occasioned much mischief.

• N B. This Preface '■ vri<! - through "-eli?""''"* 10 .- omitted ; i the 4to edition.

260 PREFACE

I should be sorry to have what I say misunderstood. I do by
no means intend either to praise or blame indiscriminately: I
think that each operation has its merit; but I also think, and
know, that we have almost laid aside one, for reasons which arc
not founded in truth; and that we have rather hastily patronised
and practised the other, without duly attending to its very fre-
quent ill consequences.

The second tract regards a disease which is mentioned, indeed.
in most books of surgery, but in general not in such manner as to
enable a young practitioner to form a proper judgment of it.
By some, it is passed over so slightly, that an ignorant reader
might be induced to suppose that it could never occasion much
trouble or hazard: by others, it is regarded merely as requiring
a chirurgic operation, to the performance of which their whole at-
tention is paid; while, both by the one and the other, the material
circumstances of the disease are overlooked, and no rules laid
down whereby to determine on the propriety or impropriety of
any chirurgic attempt whatever.

The subject of the third has not (at least to my knowledge)
been publicly noticed

All who have the care of hospitals in this town know, that the
chimney-sweepers 1 cancer is as real, and as peculiar, a distemper
as any of the moibi artificium; and a very melancholy considera-
tion it is to those who are necessarily in the way of being liable
to it.

The fourth is the result of a custom which I have many years
practised; that of making memoranda of whatever appeared to me
to be either unusual in itself, or attended with any singularity of
circumstances.

The fifth is on a disease, which has so generally foiled all the
-attempts of art, as to be by many reckoned among those which are
out of its reach. This truth, though sometimes undeniable, is

PREFACE. 261

always acknowledged with reluctance; and reasons, good or bad,
are therefore always sought for, and given for our disappointment.
In the present case, a defect of circulation, an ossification of ves-
sels, a want or depravity of the nervous fluid, with some other
conjectures, equally ingenious, whimsical, and groundless, are
offered. Whatever may be the original cause of the mortification
of the toes and feet, certain it is, that acute pain is one of its first
and most constant symptoms; and as certain it is, that whi.le such
pain continues, no stop is, or can be, put to the progress of the
distemper. The ideas of defective circulation, want of sensibility
in the nerves, of malignity, putrefaction, &c. have, in my opinion,
misled us from a proper consideration of this destructive malady,
and have put us on a plan of practice, which, as far as it relates to
externals, seems to me to be opposite to that which ought to be
pursued, and to render the disease more intractable, and more
certainly fatal. Instead of cooling, we endeavour to excite heat;
and when the parts which yet retain life and sensation, are in
such state as to be most liable to, and susceptible of irritation, we
apply to them hot, pungent oils, balsams, and tinctures, and wrap
them up in cataplasms made of such ingredients as are more cal-
culated to answer the purpose of stimulating than of appeasing.

In short, I cannot help thinking that we have, in this case, done
what our forefathers did in that of wounds made by gun-shot;
that is, we have formed conjectures, concerning the nature of the
distemper, which are not true, and then have built a practice on
these erroneous guesses. The strange notions which our ances-
tors entertained concerning the effects of fire, the poison of gun-
powder, the malignity and the putrefactive disposition of gun-shot
wounds, led them to overlook the obvious and necessary effects of
a high degree of contusion and laceration, and induced them to
have recourse to such means, as, though perfectly agreeable to
their theory, necessarily increased the pain, the inflammation,

262 PREFACE.

and (he irritation which they should have endeavoured to soothe
and appease.

What the consequence of their treatment too frequently was,
themselves have told us; what that of attending more to the true
nature of the case, and of acting from such consideration has
he;n, our soldiers and sailors have of late years happily expe-
rienced.

Perhaps some of the cases which I have related in the fourth
tract, may not appear to others to be so worthy of notice as they
did to me. Some of them, I cannot help thinking, may deserve
the attention of the younger part of the profession, to whose infor-
mation I wish to contribute.

Diseases have, it is true, in general, a sort of regularity and
order; a series of causes and events, by which they are known and
distinguished; yet we do now and then meet with such odd irre-
gularities, such strange and unusual consequences, as puzzle and
alarm even the soundest judgment, and the longest experience;
and unless these be noted, the history of distempers will be imper-
fect.

From writers of systems and institutes, (of surgery at least,)
such kind of knowledge is not to be expected. They are most
frequently mere compilers, and do little more than copy each
other. The information which they convey is, at best, but super-
ficial, and much more calculated to enable man to talk, than
either to judge or to act. It must be from a careful attention to
the casts of individuals, and from an observation of diseases, in
their irregular and infrequent forms, as well as their more cus-
tomary ones, that true and extensive judgment can be acquired.

If, therefore, a faithful relation of these less usual circumstances
and appearances, both in the living and in the dead, were more
frequently made, it might be productive of no small improvement:
it would not be confined to the adding a few anomalous, eccentric

PREFACE. 263

cases to our books, tending to excite our admiration only, but
might be made to serve a much more valuable purpose: if might
guard us against too hastily determining in cases of real, or of
seeming obscurity, and might prevent us, now and then, from
supposing things to be incapable of being accounted for, merely
because we have not yet learned how to account for them; it
might, perhaps, lessen our faith in general doctrines and theories,
but it would render us more attentive to facts, and thereby fur-
nish us with a much more useful kind of knowledge.

Perhaps, also, upon a more close and frequent examination, we
might find, that some of these very cases are neither so rare, nor
so intractable, as we have hitherto believed them to be. But be
that as it may, certain it is, that from such inquiry we should at
least get one kind of information — we should be furnished with
good and satisfactory reasons, why our best attempts so frequently
fail. I say satisfactory, because I cannot help thinking, that next
to the pleasure of being able to relieve the distresses of mankind,
is the satisfaction of knowing that it was not in our power so
to do.

Many and great are the improvements which the chirurgic art
has received within these last fifty years; and much thanks are
due to those who have contributed to them; but when we reflect
how much still remains to be done, it should rather excite our in-
dustry than inflame our vanity.

Our fathers thought themselves a great deal nearer to perfection
than we have found them to be; and I am much mistaken, if our
successors do not, in more instances than one, wonder both at our
inattention and our ignorance. Notwithstanding all our late real
improvements, there is still ample room to exercise all the powers
of many succeeding artists, and to furnish thein.with large oppor-
tunity of acquiring honour to themselves, and of doing much praise-
worthv service to mankind: the art is still defective, and the

264 PREFACE

words of Seneca are still, in some degree, as true as when he wrote
them, " Multum adhuc restat operis, multumque restabit; nee
" ulli nato post mille secula praecludetur occasio aliquid adhuc
" adjiciendi."

REMARKS ON THE CATARACT.

Notwithstanding the variety of operations and processes
which, for the relief or cure of this disease, are to be found in al-
most all the books of our forefathers, yet it is very certain that un-
til within these last fifty years, neither the state, nature, nor seat
of it were truly known; at least not to the practitioners of sur-
gery-
Wild and various were the conjectures concerning it: it was

by some said to be a distemper of the vitreous humour; by others
of the aqueous: by some it was thought to be a condensation of
earthy particles; by others a membranous film: it was said by
some to be anterior, by others posterior, to the pupil: it was often
confounded with the gutta serena, and sometimes even with an.
opacity of the cornea

Accident, one great source of many an useful discovery both in
physic and surgery, first proved it to be a distemper of the corpus
crystallinum; lo be in general absolutely confined to it, and to con-
sist of a greater or less degree of opacity; and now, as is usual in
all such cases, we are convinced, that all the attempts, and all the
operations, which ever were made or practised to any good pur-
pose, either for its relief or its cure, could be successful only as
they affected that body.

From the knowledge of its seat, and of one of the principal
circumstances of its nature, we have been enabled to direct our
attempts more rationally, and to act with a greater degree of pre-
cision and satisfaction; but still from all I have been able to col-
lect, either from books or from practitioners, there are some ma-
terial circumstances relative to the disease, which are not rightly, at
least not generally understood: some remains of the old doctrine still

vol. II. T - *

26& REMARKS ON THE CATARACT.

continue to influence both our opinion and practice; some things
are taken for granted which are by no means true; and practical in-
ferences are drawn from others, which are not admissible. Whether
an attempt to set some of these in a clearer light, will or ought
to be attended with any alteration in the treatment of the distem-
per, must be left to others to determine: I shall content myself
with relating, as briefly as I can, some few particulars which ap-
pear to me to deserve attention.

One general opinion among our ancestors was, that every cata-
ract had its seasons; was at one time immature or unripe; at
another mature or ripe; and that the term unripe, necessarily im-
plied a soft — that of ripe, a hard or firm slate of the crystalline.

The opinion was a necessary consequence of the theory then
most frequently embraced, and was therefore generally credited;
and, as very often happens with regard to preconceived notions, it
was thought to be confirmed by facts.

This doctrine has, it is true, been contradicted by some of our
best modern practitioners; but still it not only remains the opinion
of many, but has a very considerable share in determining the
preference supposed to be due to one method of operating over
another.

The terms imply, and are generally understood to mean, that
every cataract is at first soft through its whole substance; and that
by degrees, in more or less time, it becomes hard and firm, or at
least harder and firmer than the natural crystalline; which latter
circumstance is by no means true, either necessarily or even gene-
rally. I will not say that it never is; but I can venture to affirm,
that it most frequently is not. Some of our remote ancestors bor-
rowed their ideas on this subject from the kernels of fruits, to
which they have indeed compared the cataract; but the notions of
ripe and unripe have remained with many who were aware of
the exceeding absurdity of the comparison.

If this was a merely speculative point, it would be a matter of
very little importance; but as a practical inference is drawn from
it, that the early, or supposed unripe state is an improper one for
an operation, and that therefore a patient should wait for a later
or ripe one, it becomes a matter of considerable consequence to
such person, whether he shall or shall not continue bli*d all that

REMARKS ON THE CATARACT. 267

very uncertain space of time. Neither is this all, material as it
may seem; for the same doctrine implies, that the first degree or
appearance of obscurity, however soft the crystalline may then
be, will certainly be followed by an induration of it; or in other
words, that the crystalline is first rendered soft merely, and only
to become hard afterwards; that the same first or soft state is not
proper for an operation, because it would necessarily render it un-
successful; and that an increased degree of opacity and obscurity,
may in general be regarded as marks of increased firmness: not
one of which is true.

The natural, sound, transparent crystalline, is very far from be-
ing uniform in its consistence through its whole substance; its ex-
ternal part is much softer, and more gelatinous than its internal;
which therefore, although equally transparent, may be said (o form
a kind of nucleus, and is always of much firmer texture.* From
this sound and natural state, it is capable of several morbid altera-
tions; it is capable of being dissolved, or of becoming fluid, with-
out losing any thing of its transparency ; b it is capable of being dis-
solved into an apparently uniform fluid, of a gelatinous kind of
consistence, but which will be more or less opake through the
whole; it sometimes becomes opake while it undergoes a partial
kind of dissolution, which leaves or renders the different parts of
it of very different degrees of consistence; and it now and then,

a If this known difference of consistence between the external and inter-
nal parts of the crystalline was duly attended to, it would solve many of the
appearances in cataracts which, for want of such attention, are either not ac-
counted for, or very absurdly. Among otiier phenomena, it would account
for the very different colour which the different parts of the same cataract
frequently bear; and which lias furnished the wildest conjectures.

f> It has been supposed, by very good anatomists, that the human crystal-
line has sometimes, between its surface and its capsula, a small quantity of
fine pellucid lymph ; and consequently that there is no immediate connexion
between that body and its investing membrane. In many beasts, as well
as fishes, this is known to be the case ; but whether it be so in the human eye,
is not very easy to be known during life ; but that this is the case, sometimes
from distemper, I have no doubt. I mean, that the whole crystalline is dis-
solved into a fluid, still preserving its transparency. This kind of alteration,
as I take it, forms what is by some called one species of the gutta serena ; by
others, the black catai'act.

268 REMARKS ON THE CATARACT.

though very rarely, becomes opake through its whole substance,
and yet preserves its natural degree of firmness.

Whenever the crystalline becomes softer than it should be, or
tends towards such state, it is certainly distempered, and unfit for
perfect vision, whether it be opake or not, or whatever its de-
gree of opacity may be; but whoever supposes that such softened
and opake crystalline will necessarily, or even frequently, ac-
quire firmness, or become hard by time, is exceedingly mistaken.
Opacity, though now and then accompanied by what is called in-
duration, is no proof of it, nor of any tendency towards it; so far
from it, that some of the most dissolved or fluid cataracts, and
which have been so for the greatest length of time, are found full
as opake as the most firm ones.

Whoever has an opportunity of observing this distemper, and
will embrace it, will find that cataracts which have in a length of
time gone through all those alterations of colour, which are said
to indicate unripeness and ripeness, are often as perfectly soft as
they ever could have been; and, on the other hand, will some-
times find them what is called firm or hard very soon after the
first appearance of obscurity. That is, to speak more truly, as
well as more properly, the former having been at first dissolved,
have remained in the same state of dissolution; and the latter,
having been at first only partially softened, have been found in the
Same unequal state, with a firm nucleus. d

When, therefore, I make use of the term induration, I do it in
compliance with the common method of speaking; and not be-
cause I think it conveys, by any means, an adequate idea of the
real alteration made in the state of the crystalline: far from it; it

c Frorr. this variety of alteration, which the crystalline is capable of under-
going, proceeds that variety of appearance which our ancestors have called
so many different kinds of cataracts.

d For there is no possibility of accounting rationally, but by having recourse
to the natural state of the crystalline, with regard to the different consist-
ence of its different parts. This will account for the alterations to which it
is liable from time, accident or distemper : this will show why there is no uni-
formly and universally hard cataract ; why, in all of them, the softest part is al-
ways on the surface ; why, even in the hardest, the central part is always the
most firm ; and why the external and internal parts of the same, cataract, are
so often so different from each other in colour.

REMARKS ON THE CATARACT. 269

neither conveys an idea of the nature, nor of the extent of such al-
teration. With regard to the former, the term induration can with
propriety be used only in opposition to a perfect or general distem-
pered dissolution; by much the majority of what are called firm
cataracts, being much less firm than the same crystalline was be-
fore such alteration; and with regard to the latter circumstance,
the extent of the mischief, it is subject to the greatest degree of
uncertainty; being seldom or never an induration of the whole
body, but most frequently a firmish kind of nucleus, of greater or
less size, contained within more or less of a gelatinous, or softer
kind of substance: so that the nucleus is called firm only in oppo-
sition to what envelopes it.

In short, if we would think and speak of this matter as it really
is, (or as it appears to me to be,) instead of using the terms soft
and hard in opposition to each other, and as implying different
effects, either of time or of distemper, on the crystalline, we should
say, that dissolution or softening, in some degree, is by much the
most common effect; that, except in some few instances, where
that body retains its natural firmness, while it loses its transpa-
rency, the most frequent consequence is a softening of its texture,
either partial or total; and that seven times in nine, when the
crystalline becomes opake, and tends towards forming a cataract,
it is more or less softened; sometimes equally through its whole
substance, sometimes partially, having a greater or less portion
left undissolved.

This undissolved part, which always makes what is called a
hard cataract, may indeed be called firm in opposition to the
softer, by which it is surrounded; but even this very part is hard-
ly, if ever, so firm as the centre of the natural and sound crys-
talline.

I beg the reader's pardon for having been somewhat prolix,
but the subject did not appear to me to have been properly at-
tended to.

It would be exceedingly pleasant, as well as advantageous, if
we could, previous to an operation, know the true state of an
opake crystalline: it would enable a surgeon to determine his
mode of operating with more precision, and to explain what his
intention by such mrthod was: it would give satisfaction to him-

270 REMARKS ON THE CATARACT.

self as well as to standers by; and make that appear to be judi-
cious and rational, which, under our present uncertainty, has often
the appearance of being accidental, and done at random.

It is agreed by all, who have carefully considered this subject,
and who are ingenuous enough to speak the truth, that the mere
colour of a cataract furnishes no proof, to be by any means de-
pended upon, relative to its consistence; and that they which ap-
r^ar greyish, or bluish, or like whey, are sometimes found to be
firm and resistent, while the more equally white ones are per-
fectly soft.

I do not mean to assert, but merely to propose to the consider-
ation of such as may have leisure and opportunity, whether, when
the opake crystalline is quite dissolved, so as to form a soft ca-
taract, it is not, at the same time, somewhat enlarged; and
whether, when such dissolution does not take place, and what is
called a hard cataract is formed, the crystalline is not, in some
degree, lessened or shrunk?

Among the circumstances which have concurred to incline me
to be of this opinion, is this; that when the pupil has been ob-
served to be always in a state of dilatation, even when exposed
to a strong light, and, although capable of motion, yet never to
contract in the usual manner, 1 have most commonly found the
cataract to have been soft; and, on the contrary, when the pupil
has been capable of full and perfect contraction over the cataract,
I think that it has most commonly proved firm; and this differ-
ence I have more than once observed in the different eyes of the
same person. The greater degree of facility with which the firm
cataract quits its place, and passes through the pupil upon the di-
vision of the cornea, does not lessen the probability of this opinion.
I could also wish that they who have an opportunity would in-
quire, whether the cataracts which have been found perfectly soft,
have not, in general, become gradually more and more opake by
very slow degrees, and, in a length of time, the patient feeling lit-
tle or no pain; and whether the firm ones do not, in general, be-
come hastily opake; and are not preceded, or accompanied, by
severe and deeply seated pain in the head, particularly in the
hinder part of it?

REMARKS ON THE CATARACT. 271

What has hitherto been said, as it principally regards the theory
•f the distemper, may perhaps be thought to be of little import-
ance; but when the influence which these opinions may produce,
and indeed have produced on practice, is considered, it will be
found to be matter of some consequence: while they are confined
to a surgeon's imagination only, they are not of much considera-
tion; but when they are to regulate his judgment, and direct his
hand, they become rather serious.

Since the operation of extracting the cataract, instead of de-
pressing it, has been introduced into practice, and made a kind
of fashion, it has been the humour to exaggerate all the objections
to which the latter has been said to be liable; and that in such a
manner, that they who have not had frequent opportunities of see-
ing business of this kind fall, without reflection, into the prevail-
ing opinion, seem to wonder, that the operation of couching should
ever have had any success at all; and at the same time are, from
the accounts given, inclined to believe, that the extraction is al-
ways safe, easy, and successful.

The objections which are made against the operation of couch-
ing, at least those which have any semblance of truth or force, are
reducible to four.

The first is, that if the cataract be perfectly soft, the operation
will not be successful, from the impossibility of accomplishing the
proposed end of it.

The second is, that if it be of the mixed kind, partly soft and
partly hard, it will most probably fail of success, not only from the
impracticability of depressing the softer parts, but also because the
more firm ones will either elude the point of the needle, and, remain-
ing in the posterior chamber, still form a cataract; or getting
through the pupil into the anterior chamber, will there bring on
pain and inflammation, and induce a necessity of dividing the
cornea for their discharge.

The third is, that if the cataract be of the firm, solid kind, and
therefore capable of being depressed, yet, in whatever part of the
eye it shall happen to be placed, it will there remain undissolved,
solid, opake; and although removed from the pupil, yet prove some
hinderance to perfect vision.

272 REMARKS ON THE CATARACT.

The fourth objection is, that however successfully the depression
may have been accomplished, yet that the operation will necessa-
rily occasion such violation and derangement of the internal parts
of the eye, as must cause very considerable mischief.

These objections, if they have any real weight, are of equal force
in every species of cataract — -and therefore are the more worthy
our attention; since, if they be founded on truth, they render the
operation unfit for practice; but if they be not, misrepresentation
and fashion should never induce us to lay aside any means which
have been, and still may be, beneficial to mankind.

The first and second I can, from frequently repeated experience,
affirm not to be true. I mean that the operation of couching will
not necessarily, or even generally, be unsuccessful, merely because
the cataract shall happen to be either totally or partially soft; on
the contrary, although these stales will prevent perfect depression,
yet, by the judicious use of the needle, a recovery of sight (the
true end and aim of the operation) will be as certainly and as per-
fectly obtained, as it would have been, either by depression or
by extraction, in the same subject; and that, generally, without
any of the many and great inconveniences which most frequently
attend the latter operation.

The third objection is specious, and therefore very generally
credited. That it never happens I will not take upon me to say,
because so many have asserted it; some of whom, one would hope,
had some kind of authority for what they have so positively affirmed.
But, on the other hand, when we consider how few there are who
have written from their own examination and experience, and how
many who have taken for granted, and copied, what others have
said before them, our faith will not -be quite implicit. Certain I
am, from repeated experience and examination, that this opinion
has not that foundation in truth which it is generally supposed to
have; and that it has been embraced and propagated hastily, and
without sufficient inquiry and experiment.

As this supposed indissolubility of the opake crystalline is not
only so principal an Objection to the operation of couching, even
when it is capable of being perfectly depressed, as to be said to
overbalance all the evils, many and great as they are, which fre-
quently attend the extraction; but is also supposed to be the cause

REMARKS ON THE CATARACT. 21o

of the failure of success, when the depression of the softer kinds of
cataracts is attempted; it may be worth a little serious examina-
tion.

I should be sorry to have it thought, that I had any predilection
or partiality to one method of operating more than to another; or
that I would wish to give to either any preference, but what its
superior excellence or utility might justly demand. But, on the
other hand, I cannot possibly pay regard to any authority, however
otherwise respectable, when it contradicts what I know to be fact.

Both operations are equally practicable by any man who has a
hand and an eye, and is capable of performing either; but it has
of late years been so much the humour to depreciate the one, and
to extol the other, that it becomes necessary to examine the sup-
posed merits of one, and demerits of the other, and to see whether they
be drawn from premises which are true: if one is to be deemed
universally preferable to the other, let the circumstances, on which
preference is be founded, be drawn from fact, and not from fiction;
let them be fairly and faithfully inquired into, and let such inquiry
determine.

In order to assist in one part of this inquiry, I beg leave to lay
before the reader a few experiments and observations which I have
made; or, I believe I shall more properly say, have repeated; they
having been often made and observed, but not properly enforced or
applied.* 5

When the opake crystalline is in a state of dissolution, or the
cataract is what is called perfectly soft, if the capsula of it be freely
wounded by she couching-needle, the contents will immediately
issue forih, and, mixing with the aqueous humour, will render it
more or less turbid; sometimes so much as to conceal the point of
the needle and the iris of the eye from the operator.

This is a circumstance which has been observed by most ope-
rators, and has been mentioned by many writers; but it has always
been regarded and mentioned as an unlucky one, and as being in
some degree preventative of success; which is so far from being
the fact, that as far as relates to this circumstance merely, all the

* When I sav experimentsand observations which I have made andrepeated,
I would wish the reader to understand, that I have made them carefully, for
the purpose ; and so repeatedly, as to be satisfied of their srnerfl/ truth.

VOL. II. " m

274 REMARKS ON THE CATARACT.

benefit which can be derived from the most successful depression,
or extraction, most frequently attends it; as I have often and often
seen.

The aqueous humour, however turbid it may become, will, in a
very short space of time, be again perfectly clear; and if no dis-
order of the capsula of the crystalline, previous or consequential,
prevents, the rays of light f will pass without obstruction through
the pupil, and the patient will be restored to as perfect vision as

fThe capsula, or investing membrane of the crystalline, has very often
an unsuspected share in the apparent opacity of that body ; and is thereby
the cause of disappointments and inconveniences during - some operations,
and after others. This is a circumstance whicli, undoubtedly, has been men-
tioned ; but has not been by any means sufficiently attended to. The capsu-
la is capable of becoming - white and opake, while its contents shall be clear
and transparent : it becomes so sometimes by being wounded by the couch-
ing-needle, used either for the depression of a firm cataract, or for the letting
out a soft one ; and it will not infrequently be found so, after the operation
of extraction, when no instrument has touched it.

Whenever this happens, it is an unpleasant circumstance; but still more
so if it continues for any length of time : I have seen it disappear in a week ;
I have seen it continue two, three, or four, and at last totally disappear ; and
I have seen it continue so long as to require the re-application of the in-
strument. When it appears after the depression of a firm crystalline, or
after an unsuccessful attempt to depress one which has proved not firm
enough, it may easily be, and generally is, mistaken for a portion of the
cataract risen again ; but from which an attentive observer will always
be able to distinguish it. But when such opacity follows what is called a
successful extraction, in which the cornea only was divided, the capsula
not touched by the instrument, and the cataract came away intire through
the pupil, the case is self-evident.

This may truly and properly be called, as it has been by Monsieur Houin,
Haller, and others, a membranous cataract, as it consists merely of the mem-
branous capsula of the crystalline.

W nters of credit have mentioned, that a cataract may be formed almost
instantaneously, by external violence. There is no doubt of the fact ; I
have seen it four different times.

Whether this be not an affection of the capsula merely, I much doubt; or
ratlier am much inclined to suspect that it most frequently is. In three of
the four, which have fallen under my observation, the opacity has gradually
disappeare I after the inflammation, in consequence of the blow, had gone
off; and the eyes were left as clear as ever — a consequence which, I think,
may be accounted for, by supposing the opacity in the capsula only ; but
cannot, if we suppose it to be in the corpus crysiallinum itself.

REMARKS ON THE CATARACT. 275

could have followed the most successful operation of either, or of
any kind in the same subject, and under the same circumstances.
When the cataract is of the mixed kind, partly soft, and partly
hard, the immediate effects of the needle are somewhat different;
the soft part of the cataract being less in quantity, as well as gene-
rally less soft, the aqueous humour is less turbid, and the firm part
or parts of the crystalline will be very visible. In this state,
these firmer parts will very frequently elude the attempts made
by the needle to depress them; and will therefore remain in the
posterior chamber. This is also reckoned among the unfortunate
circumstances; but although to an operator not aware of, nor ac-
quainted with the consequence, it may have all the appearance of
being so, yet it really is not; the true end and aim of the opera-
tion not being thereby necessarily frustrated. In this case, if the
needle has been so used as to have wounded the capsula very
slightly, it will sometimes happen, that the firm part of the crys-
talline will remain in its nidus, and still form a cataract, which
may possibly require a future or re-application of the instrument.
This is the worst that can happen, and happens indeed very seldom;
for if the capsula be properly wounded, so that the aqueous hu-
mour be freely let in, the firm part or parts, though very visible at
first, and preventing the passage of light through the pupil, will,
in due time, in some longer, in others shorter, gradually dissolve,
and at last totally disappear; leaving the eye as fair, as clear, and
as fit for vision, as any the most successful operation could have
rendered it, of which I have seen and exhibited many proofs. 8

e The space of time which the accomplishment of such dissolution will re-
quire, is very uncertain; I have seen 'he eye perfectly fair and clear within
a week after the operation ; and I have seen it require two months for the
dissolution of all the opake parts.

This has been observed by many, even before the nature and sea of a ca-
taract were truly known ; among the rest, by Read, who, speaking of one of
his own operations, says,

" At the end of nine days, I visited my patient, and found both her and
"her friends highly discontented; so that 1 met with nothing but invec-
" tives, 8tc.

" Within a fortnight after, when art and nature having performed theii
" mutual operations, and all the cloudy vapours and rags of the cataract n e.
" consumed and dispersed, her eyes grew clear, and her sight became per
" feet, &c.

276 REMARKS ON THE CATARACT.

In order to render the fact still more clear, I have sometimes,
when I have found the cataract to be of the mixed kind, not at-
tempted depression; but have contented myself with a free lacer-
ation of the capsula; and having turned the needle round and
round, between my finger and thumb, within the body of the crystal-
line, have left all the parts in their natural situation; in which
cases I have hardly ever known them fail of dissolving so entirely as
not to leave the smallest vestige of a cataract. 11 In a few instances,
where I have had fair opportunity, I have pushed the firm part
through the pupil into the anterior chamber, where it has always
gradually and perfectly dissolved and disappeared, not producing
pain or trouble, while such dissolution was accomplishing.'

" I would have every patient, though after a cataract he couched, and nine
" or ten days expired, he see little or nothing at all, or that he cannot endure
" the light for a month or two, or even for a qu rater of a year, as I have
" known many, not to be discouraged ; for their sight may, notwithstanding,
" become well and perfect, and continue so ever after. On the other hand,
" some come to good and perfect sight within a fortnight or three weeks."

Sir W. Read, p. 7.
h The operation of extraction, though said in general to remove the crystalline
intire, and calculated for such purpose, does not always do so : but when the
cataract is of the mixed kind, does not infrequently leave some of the firmer
part behind; which one of the warmest patrons of the operation allows does
dissolve and disappear. " Extrahendum statim post operationem est quic-
" quid remanet opaci ope Cochlearis Davielis. Hoc quidem facile sit ali-
" quando, aliquando vero et imprimis ubi membrana crystallina non satis la-
" cerata cochlear in ipsam capsulam lentis, ubi hsret illud opacum corpus-
<: culum non admittit, tantis difficuitattbus circumfusum est, ut quicquid
" etiarn mcliaris extrahere illud non possis, et ne oculum nimis irrites, desis-
" tere ab opere, et rclinquerc illud in oculo cogaris.

"Neque tamen tunc etiam spe optimi successus destituimur. Srepe enim
" observavi, opacum illud remanens, sive sit mucus, sivc frustulum lentis crys-
" tallinx, sensim, et sponle, citius \e\ tardius, penitus disparuisse. An resor-
" betur mucus lacteus, an frustula lentis crystalline liquescant sensim, et re-
*' sorbentur, an in fundum oculi sensim, se precipitant, dubium est. Utrum-
" que tamen fieri credo. Quoties lactea materia post deprcssam cataractam
" totum humorem aqueum opacitate sua et albedine inficiens sensim peni,
"tusevanuit? Quoties pus in oculo haerens vel sanguis insigni quantitate
"in ilium effusus, sensim resorptus evanuit ? Quoties frustula lentis crys-
" tallins, post depressionem cataract*, in pupil la relicta ? &c. immo liqucs-
" cere aliquando et resorberi hxc frustula me ipsum experientia docuit." &c.

Ricutkr de Cataracta: Extract.

' I should be sorry to have it inferred from hence, that I would recommend
the passing the opaque crystalline through the pupil : far from it ; 1 think it

REMARKS ON THE CATARACT. 277

What I have advanced not being matter of opinion, but matter
of fact, capable of being inquired into, and proved by any who
will take the trouble of so doing, I do not desire any man to give
credit to it upon my mere assertion. But if, upon repealed trial
and inquiry, it should be found to be as generally and as frequently
true by others, as it has been by me, may it not fairly be inferred,
that whatever other reasons there may be for preftrring the ope-
ration of extraction to that of depression, or the use of the knife to
that of the needle, yet those drawn from the supposed indissolubi-
lity of the crystalline are by no means conclusive; on the contrary,
are very inconclusive. But this is by no means all; for if what I
alleged be true, some other consequences, not a little interesting
to the afflicted, will necessarily follow.

First, if the soft cataract will, when its capsula is properly
wounded, mix with the aqueous humour, and undergo such a per-
fect dissolution and absorption, as to leave the eye fair, clear, and
fit for vision, and which I have so often proved, that I have not
the smallest doubt about it; it will then follow that the softness of
a cataract is so far from being an unlucky circumstance, that it is
rather a fortunate one; as it enables the patient to receive more
early assistance; and that from an operation attended with less
pain, and a less violation of parts, than a firmer one would ne-
cessarily require.

Secondly — When the cataract is of the mixed kind, and which
therefore frequently foils all the attempts toward depression, the
firmer parts may very safely be left for dissolution; and vision be
thereby restored.

And, Thirdly — When the cataract shall happen to be of the
firmer kind, and during an unsuccessful attempt to depress, get
through the pupil behind the cornea, disappointment will be so far
from being the consequence, that if no other injury has been done
to the parts within, than what such attempt necessarily required,
the displaced crystalline will gradually dissolve and disappear;

wrong, as it is apt to produce one of the most frequent inconveniences at-
tending the operation of extraction— an irregularity of the pupil. I onlymeant
to prove the fact of dissolution of the cataract in such situation; and that it
ot cause that pain and trouble which it is so positively said to do.

278 REMARKS ON THE CATARACT.

and the patient will see as well as any operation could have ena-
bled him to have done.

I may perhaps be told, that what I have hitherto alledged only
tends to prove, that both the soft and mixed cataract, when mixed
with the aqueous humour by the laceration of the capsula, will
dissolve; but that the firm one will not, and therefore must remain,
wherever placed, a solid opake body.

To which I answer, in the first place, that if what has been said
relative to the soft, and to the mixed cataract be true, I cannot
help thinking it to be very advantageous. In the. second place,
that the opinion concerning the indissolubility of the displaced
crystalline has, I think, been taken up, and propagated, without
proper authority from inquiry and experiment, fairly and deliber-
ately made, and stands merely on a few accidental observations,
which are by no means satisfactory. And, in the third place, that,
as far as my own inquiry and observation go, I am satisfied that
it does dissolve wherever placed, provided it be perfectly freed
from its attachment in its natural nidus.fc

Both men and books talk of firm, hard, intire, uniform cataracts,
as if they were as much so as what are found in the eye of a boil-
ed fish. Whence they borrow this idea, I know not, unless it be
from boiled fish; certain I am that it is not from nature.

Let any man examine the most firm, opake crystalline, taken
from the eye of a living person, and which, from its firmness, pass-
ed out through the* pupil and the divided cornea with the greatest
facility; he will generally find it to be in figure, size, and consist-
ence, exceedingly unlike either to the natural and sound crystalline,
or to one rendered opake by heat; and he will also find, that such
alteration of shape and size is owing to a partial dissolution of its

k While I was preparing these sheets for the press, an old man was taken
into St. Bartholomew's, who had a cataract in one eye, and had, by some ac-
cident, lost the sight of the other. I couched him ; the cataract was as firm
as I had ever felt any, and went down as easily, as immediately, and as intire -
ly as possible. Three days after the operation, he was seized with so bad a
small-pox, that he died on the eleventh, and the next day I took his eye
home and examined it. The cataract lay just below and behind the uvea,
towards the external cantlms. It was become small, irregular, and manifest-
ly in a state of dissolution.

REMARKS ON THE CATARACT. ~~9

surface, particularly its anterior one; in short, if he will examine
it carefully, and without prejudice, he will see, that what he calls
an intire, firm cataract, is most frequently little more than the
nucleus of an opake crystalline.

If a man might be allowed to argue in a case of this kind, a pri-
ori, he might very reasonably ask, why should the corpus crystal-
linum, which although opake, is, while in its natural situation, and
enveloped in its proper capsula, so prone to dissolve, as we must
know that it is, be supposed to be as prone to induration, immedi-
ately upon being removed from its place.

The most strenuous advocates for extraction cannot help al-
lowing, that a portion or portions of a firm cataract, which they
have been obliged to leave behind in the operation, dissolve and
disappear in due time: it is, indeed, a fact not to be contradicted;
but the same people say, that the intire cataract will not. What
idea they, who argue thus, have of an intire cataract, I know not:
they may possibly conceive it to be depressed, still remaining en-
veloped in a firm capsula, and therefore to remain indissoluble;
but if they would reflect on the extreme fineness of the capsular
membrane; on the necessary action of the couching-Jieedle, when
applied to it; and on the different consistence of the different parts
of every, even the most opake and firm cataract, they must see
that it is a portion only of any cataract, however firm, which can
in general be depressed.

One of the arguments, made use of by some of the late writers,
in favour of extraction, is, that as the crystalline must be destroyed,
it had better be removed. Now how can it be said to be destroy-
ed, if it be only displaced, and remain indissoluble? Let them
take which side of this argument they please, they must be wrong;
for if the diseased crystalline remain, though depressed, a solid
body within the eye, how can it be said to be destroyed? and on
the other hand, if it be destroyed in the operation of couching, it
must be by dissolution; and therefore cannot remain.

The last objection to the operation of couching is, that it must
necessarily derange and violate the internal parts of the eye, par-
ticularly the vitreous humour.

• If what I have said on the subject of the perfectly soft cataract,
as well as on that which is partially so, be true, the greatest part,

280 REMARKS ON THE CATARACT.

if not (lie whole of this objection, will cease, with regard to these
two; and it will be principally, if not totally, confined to that
which is called firm and hard, and which, by its resistance to the
instrument, will admit of being placed in the inferior part of the
eye.

In the performance of this operation, the needle may certainly
be so used, as to do considerable mischief; but then it must be
from the unskilfulness or awkwardness of the operator; and which
may be the case of every operation in surgery. But is an opera-
tion, justly chargeable with ills, deducible merely from its having
been ill executed? — I hope not.

I am very sensible that much mischief has been done by at-
tempts to couch; but, in the first place, they have almost always
been the consequence of want of judgment, or want of dexterity
in the operator; and, in the next place, even under the most ex-
aggerated representations, they are by no means equal to what has
frequently been the consequence of attempts to extract.

It may possibly be supposed, that I have conceived a prejudice
against the operation of extraction. Of this I am not conscious.
I have sought and embraced every opportunity which a public
hospital, and many years practice, have afforded me of operating
in both ways, and of comparing the consequences. I have seen
many of the patients of others, not only of the gentlemen of the
profession, but of most of the itinerant operators; and am thereby
convinced, that the greatest part of the objections to the operation
of couching are invalid; have not been the result of unprejudiced
experience, or a candid regard for truth; that only the fair and
prosperous side of the question, regarding the operation of extrac-
tion, has been industriously exhibited, while its manifold failures
and ill consequences have been as industriously concealed, and that,
upon a fair detail and comparison of all the advantages and dis-
advantages, conveniences and inconveniences, attending each, the
preference will be found justly due to the needle.

Inconveniences and disappointments they are both too liable to:
I heartily wish they were not. But, from the most cool and candid
attention to fact, I am convinced, that the former are much
greater, and the latter much more frequent, in the operation of
extraction, than in that of depression, executed with the same de-
gree of judgment.

The couching-needle which is commonly in use, has on the face which
is applied to the cataract, a flat, highly polished surface, which makes it, as
I have experienced, liable to slip, if it meets with any little resistance when
in contact with the surface of the cataract ; or if the crystalline breaks, it
does not readily attach the small portions of it. As the other side, near the
point, is necessarily convex, to give a proper degree of strength to the in-
strument, I conceived that an advantage might be drawn from its form to
obviate the inconvenience. I therefore got some needles made with a small
cavity on the flat side, the opposite convexity allowing sufficient depth for
it, and the surface of this cavity was left rough and unpolished. I have used
them many times during several years, and I am of opinion that this altera-
tion gives a considerable advantage in laying hold of that small slippery
body, the lens, or any fragment of it, and in conducting it to whatever part
of the eye we think proper : by a turn of the instrument it is immediately
disengaged, and neither the entrance nor passage of the needle is in any
degree impeded by it.

The annexed figures show the difference between the two needles. E.

VOL. II. * n

SOME FEW REMARKS

POLYPUS OF THE NOSE.

In these, as in the preceding remarks on the cataract, I do not
mean to enter into a circumstantial history of the disease, but
merely to offer a few practical observations on such parts of the
doctrine concerning it, as appear to me to have been either inad-
vertently or erroneously delivered.

The polypus is a complaint which is always troublesome, fre-
quently painful, and sometimes hazardous: the first of these is the
necessary consequence of the situation of the distemper; the se-
cond arises from its peculiar nature in the individual; and the last,
sometimes from its particular nature, and sometimes from the man-
ner in which it may have been treated.

Writers tell us, and very truly, that it is a disease of the mem-
brana pituitaria narium; that it has different seats, origins, and
attachments; that it springs from the ethmoid bone, from the ossa
spongiosa, from the septum narium, and even from the antra maxil-
laria; that it is hard or soft, pale or deep red, or sometimes pur-
ple; that it is equal in its surface, or unequal; large or small,
moveable or fixed, single or multiform, painful or indolent; that
it makes its appearance forward in the nostrils, or backward in
the fauces behind the uvula; and that it may be strumous, vene-
real, or cancerous. When they have given us these general and
merely definitive descriptions, they immediately proceed to the
chirurgic treatment, or method of cure; which, they tell us, is
either by extraction, or the use of escharotics; to which some have
added ligature: they then give a general description of the man-

284 ON THE POLYPUS

ner of using the forceps, of applying escharolics, or of passing the
string round it; and having provided styptics for the suppression
of haemorrhage, they leave every thing else to the reader's ima-
gination, and to the practitioner's choice and judgment.

From these accounts, those who have not had much opportunity
of seeing for themselves, and who are thereby under a sort of ne-
cessity of forming their opinions, and regulating their practice, by
books, are induced to believe that, except in some few particular
instances, where the distemper is palpably cancerous, all others
are equally objects of chirurgic treatment; and therefore, that if,
in the first instance, they can lay hold of the polypus with the
forceps, and, in the second, can provide against the haemorrhage,
which they have heard so much of, they shall have nothing else to
do or to fear.

To me I must acknowledge the matter appears very differently.
I cannot help thinking, that there are many polypi, which, al-
though they are neither scirrhous nor cancerous, are very unfit for
any chirurgic treatment whatever, and that from several circum-
stances; which circumstances may act in different manners, though
equally prohibitory: they may forbid an attempt, merely from the
impossibility of its being successful; or they may forbid it, because
it is more likely to do harm than good, more likely to exasperate
the disease than cure it, to increase the misfortune than to
lessen it.

The distinctive marks of the distemper, as laid down by wri-
ters, are, in general, just and true; but they only teach a young
practitioner to know the disease when he may see it: they give
him no warning of the mischief he may incur by attacking it un-
guardedly, nor inform him of a very serious truth, viz. that this is
a sort of case, in which, when real mischief has been done, it is
sometimes without remedy.

As far as my experience and observation go, the polypi which
begin with, or are preceded by, considerable or frequent pain in
the forehead and upper part of the nose, and which, as soon as
they can be seen, are either highly red, or of a dark purple co-
lour; they, which from the time of their being first noticed, have
never been observed to be sometimes bigger, sometimes less, but
have constantly rather increased; they in which the common ac-

OP THE NOSE.

285

lions of coughing, sneezing, and blowing the nose, gitfe pain, or
produce a very disagreeable sensation in the nostril and forehead;
they which, when within reach, are painful to the touch, or which,
upon being slightly touched, are apt to bleed; they which seem to
be fixed, and not moveable by the action of blowing the nose, or
of deriving the air through the affected nostril only (where the
polypus is only on one side); they which are incompressibly hard,
and which, when pressed, occasion pain in the corner of the eye,
and in the forehead, and which, if they shed any thing, shed blood;
they which, by adhesion, occupy a very considerable space, and
seem to consist of a thickening, or of an enlargement of all the
membrane covering the septum narium; they which sometimes
shed an ichorous, offensive, discoloured discharge; and they, round
whose lower part, within the nose, a probe cannot easily and
freely be passed, and that to some height — ought not to be attempt-
ed, at least by the forceps, nor indeed by any other means with
which I have the good fortune to be acquainted; and this for rea-
sons obviously deducible from the nature and circumstances of
the polypus. On the one hand, the very large extent and quantity
of adhesion will render extirpation impracticable, even if the dis-
ease could be comprehended within the forceps, which it very
frequently cannot; and, on the other, the malign nature of the dis-
temper may render all partial removal, all unsuccessful attacks on
it, and indeed any degree of irritation, productive of the most dis-
agreeable consequences.

But the polypi which are of a palish or greyish light brown
colour, or look like a membrane just going to be sloughy; they
which are seldom or never painful, nor become so upon being
pressed; they which have appeared to be at one time larger, at
another less, as the air has happened to be moist or dry; they
which ascend and descend freely by the action of respiration
through (he nose; they which the patient can make to descend by
stopping the nostril which is free, or even most free, and then de-
riving the air through that which the polypus possesses; they
which when pressed give no pain, easily yield to such pressure,
become flat thereby, and distil a clear lymph; and they, round
whose lower and visible part a probe can easily, and that to some
height, be passed— arc fair and fit for extraction; the polypus, in

286 ON THE POLYPUS

these circumstances, frequently coming away intire; or if it does
not, yet it is removcable without pain, haemorrhage, or hazard of
any kind; the second of which circumstances, I can with strict
truth affirm I never yet met with, when the disease was at all fit
for the operation.™

Of the benign kind of polypus, fit for extraction, there are two
sorts, whose principal difference from each other consists in their
different origin or attachment: that which is most freely moveable
^ithin the nostril, upon forcible respiration; which has been found
to be most liable to change of size, at different iimes and seasons;
that which has increased the most in the same space of time; that
which seems most limpid, and most freely yields lymph upon
pressure, has its origin most commonly by a stalk or kind of pe-
duncle, which is very small, compared to the size of the polypus;
while that which, although plainly moveable, is still considerably
less so than the other; which has been less liable to alteration
from air and seasons; and has been rather slow in arriving at a
very troublesome size, is most frequently an elongation of the
membrane covering one of the ossa spongiosa: they are both ca-
pable of being extracted, and that with no kind of hazard, with
very little pain, and hardly any haemorrhage at all: but the for-
mer requires the least force, and most frequently comes away in-
tire; while the latter often breaks, comes away piecemeal, and
stands in need of the repeated use of the forceps.

From the preceding observations a few practical inferences
may be drawn, such as the following: —

m They, who are affected with this sort of polypus, generally complain,
and that for a considerable time before the polypus becomes visible, that
they are perpetually catching cold, more especially in moiet or wet weather;
though they seldom have any other symptoms of such colds than the stop-
page in and discharge from the nose. They also always complain, that these
colds always deprive them of the sense of smelling. In moist weather, or
in a sudden change from dry to wet, they are also subject to frequent fits of
sneezing ; and when the relaxed membrane is most affected to very considera-
ble discharge of thin mucus, from the affected nostril. Nor do I remember ever
to have seen a polypus of this kind, which was wot immediately subject to
a change, upon the sudden alteration of the atmosphere, from dry to moist;
that is, they always become longer, fall down lower, and look fuller and
paler, and generally deprive the patient of all power of smelling.

OF THE NOSE. 28T

First, That the polypi, under the first description, very rarely,
if ever, admit at attempt toward extraction, and that not merely
from the improbability of its being attended with success, but be-
cause such attempt may be the cause of very disagreeable conse-
quences.

Second, That in those which do admit an operation, or the use
of the forceps, the degree of success will depend principally upon
two circumstances; viz. the benignity of the disease, and the de-
gree and quantity of attachment; for although the nature of the
complaint may be perfectly benign, yet it may happen, that a cure
may not be attainable, and that merely from the degree ajjd kind
of attachment. And,

Third, That the haemorrhage so much talked of, so solicitously
guarded against by writers, and so much dreaded by young prac-
titioners, will not often, if ever, be met with, in such cases as
fairly and properly admit the operation.

The polypus is a disease, which, of all others, is said to be most
difficult totally and perfectly to eradicate, and most liable to re-
production. This is, in some degree, true. It is difficult, in
many instances, to extirpate it totally, and it often does grow
again, more especially that sort which springs from the ossa spon-
giosa; but yet, that it is not so often the case as it is supposed to be.
It not infrequently happens, that there are, at the same time, two,
three, or more different polypi, each of which is perfectly distinct
from the others, and has a separable distinct attachment. When
this is the case, the lowest or most anterior, having the open nos-
tril before it, easily makes its way down, uncompressed; while the
other, or others, are not only kept up, and out of sight, but are
also considerably compressed.

When the one, which was within sight and reach, has been re-
moved, the next falls downward, and soon becomes visible; if it
was large and lax, and merely kept up by what lay before it, it is
often to be seen immediately; but if it was small, it may be out
of sight, and can only be suspected by the passage of air through
the nostril not being free, although the polypus which was re-
moved came away perfect and intire; and when it does appear, it
passes for a reproduction from the old stem, though it is really an-
other and perfectly distinct polypus, of which the intire state of the

288 ON THE POLYPUS

investing membrane, and the separation of the polypus from its
single point of attachment, will upon careful examination appear
irrefragable proofs. 11

It may, perhaps, be remarked, that, in what I have offered
concerning this distemper, I have confined myself merely to the
operation of extraction only; and have said noihing concerning the
various methods and means which have been proposed for its de-
struction.

I am very sensible that many of our books are furnished with
relations of attempts made by escharotics, and by a kind of medi-
cated setons; some of which have been said to be successful. If
I had ever found them so, I should have been glad to have related
it; but I cannot say that I have: on the contrary, all that I have
done of this kind, or have seen done by others, have served
more and more to deter me from practising it again. When
the polypus is loose, and fairly circumstanced for extraction, it is
not only the best method of cure, but is always advisable, and very
frequently successful; but when from immobility, largeness of
attachment malignity of nature, or from any other cause, it becomes
Unfit for the use of the forceps, it is always, as far as I have been
able to observe, still more unfit for caustic; nor indeed do I remem-
ber a single case, which has been so circumstanced as to render
the use of the forceps absolutely (inadvisable, where the applica-
tion of escharotics would not have been much more so, as experi-

f

n Mr. Pott was particularly competent to describe this disease, having
been troubled with polypi in his nose during 1 many years : at one time
they increased to such a degree as to dis'.end the nostrils, and almost totally
to prevent the passage of air. When they were fallen sufficiently low, Mr.
Pott took an opportunity, in moist weather, and when they were in a state
of relaxation, to extract the most prominent ones for himself, by means of a
. pair of window forceps, before a mirror. In no great length of time others
came in sight and supplied their place, which also Mr. Pott extracted in the
same manner, till he had a collection of five or six large polypi : one of
thei had a single basis, but was branched out into two large lobes ; to some
of them there adhered a small portion of bone, to which they had been fix-
ed — a sufficient proof that it required no small degree of fortitude and per-
severance to perform die operation on his own person. Of late years he had
intirely got rid of them ; bst there remained such a thickness of the whole
membrane, that he continued totally deprived of the sense of smelling— a
circumstance which he never much regretted. E.

OF THE NOSE. 289

menl, in some of them, has fatally proved. The structure and
irritability of parts within the nose, and the impossibility of con-
lining the application or limiting the effects of caustic medicine-.
in such a part, in whatever manner or form applied, are palpable
objections a priori; and the very disagreeable consequences which
have been often found to follow from the inflammation and in
tion of what it was impossible totally to destroy, have been too
serious to be slighted."

The polypus sometimes, instead of falling down the nostrii.
makes its appearance backward in the fauces behind the uvula; in
which case the general method is, to extract it by introducing the
instrument into the mouth instead of by the nose.

This, though sometimes practicable, is much more easily de-
scribed than executed; and in some people will be found absolutely
impracticable. The objection arises from the great difficulty of
keeping the tongue down in some, and in others, from their inca-
pability of permitting any thing to touch the root of that part, or
any part of the fauces, without immediately producing a spasm:
to which might be added, that, in some cases, the polypus is so ex-
panded, as almost to conceal the uvula, which is therefore liable to
be laid hold of by the instrument, to the no small detriment of the
patient.

However large, pendulous, or expanded such polypus may be.
its attachment always is, and must be within the cavity of the nose,
and therefore always within the reach of a pair of forceps intro-
duced that way, especially if the forceps be somewhat curved;
and which, when the excrescence appears behind the uvula, will
have one advantage superior to what it has when the polypus
appears in the nose; which is, that it will be applied much nearer
to the point of attachment, and therefore most likely to extirpate it
perfectly.

« The method by ligature, whether of silk or wire, is not attended with
the inconveniences of the caustic, and is certainly practicable in some
instances; but, as far as I have seen of it, is by no means equal to that by the
forceps, either for its general utility, or its capacity of perfectly eradicating
the excrescence. I know some ingenious practitioners, who approve of it ;
but I cannot say, from what has come within my knowledge, that it appear?
to m<j in so recommendable a light.
VOL. II- 00

290 ON THE POLVPUS OF THE NOSE.

I cannot leave this subject without cautioning the young prac-
titioner to be exceedingly careful in examining and inquiring into
all the circumstances previous to his undertaking a cure, lest he
should find, too late, that he has gone too far to recede.

For want of such caution, I have seen haemorrhages which have
been frightful, and inflammations which have proved fatal. I have
seen a case wherein an untoward looking polypus, and which
ought not to have been meddled with, has been so attached to a
distempered septum nasi, that it has come away with it: I have seen
the same thing happen with regard to almost the whole of theossa
palati; and I have more than once known a polypose thickening
of the membrane covering the ossa spongiosa, and septum nasi,
which, in all probability, would have remained quiet a great length
of time, so irritated by rough treatment and successless attempts,
as to render the remainder of the patient's life truly miserable to
himself, and offensive to others.

CANCER SCROTI

Ramazini has written a book De Morbis Artificium. — The
colic of Poictou is a well known distemper; and every body is
acquainted with the disorders to which painters, plumbers, gla-
ziers, and the workers in white lead, are liable: but there is a dis-
ease as peculiar to a certain set of people, which has not, at least
to my knowledge, been publicly noticed; I mean the chimney-
sweepers' cancer.

It is a disease which always makes its first attack on, and its
first appearance in, the inferior part of the scrotum; where it pro-
duces a superficial, painful, ragged, ill-looking sore, with hard
and rising edges: the trade call it the soot- wart. I never saw it
under the age of puberty, which is, I suppose, one reason why it is
generally taken, both by patient and surgeon, for venereal; and
being treated with mercurials, is thereby soon and much exaspe-
rated. In no great length of time, it pervades the skin, dartos,
and membranes of the scrotum, and seizes the testicle, which it
enlarges, hardens, and renders truly and thoroughly distempered;
from whence it makes its way up the spermatic process into the
abdomen, most frequently indurating and spoiling the inguinal
"•lands: when arrived within the abdomen, it affects some of the
viscera, and then very soon becomes painfully destructive.*

3 From the soot being- collected and remaining" in the moist rugae of the scro-
tum, it is not difficult to conceive why the disease should generally begin in
that part ; but 1 have seen the true soot-wart in the face of a chimney-
sweeper, just under the left eye, who had never suffered from the disease in,
iny other part., though bo said he ba<l some.'nnes felt little, hardnesses in the

292 CANCER SCROTI.

The fate of these people seems singularly hard: in their earl)
infancy, they are most frequently treated with great brutality, and
almost starved with cold and hunger; they are thrust up narrow,
and sometimes hot chimneys, where they are bruised, burned, and
almost suffocated; and when they get to puberty, become pecu-
liarly liable to a most noisome, painful, and fatal disease.

Of this last circumstance there is not the least doubt, though
perhaps it may not have been sufficiently attended to to make it
generally known. Other people have cancers of the same parts:
and so have others, besides lead-workers the Poictou colic, and
the consequent paralysis: but it is nevertheless a disease to which
those persons are peculiarly liable; and so arc: chimney-sweepers
to a peculiar kind of cancer in the scrotum and testicles.

If there be any chance of putting a .'-ion to, or preventing this
mischief, it must be by the immediate removal of the part affect-
ed; I mean that part of the scrotum where the sore is; for if it be
suffered to remain until the virus lias seized the testicle, it is gene-
rally too late even for castration. 1 have many times made the
experiment; but though the sores, after such operation, have, in
some instances, healed kindly, and the patients have gone from
the hospital seemingly well, yet, in the space of a [e\v months, it
has generally happened, that they have returned, cither with the
same disease in the other testicle, or in the glands of the groin,
or with such wan complexions, 6uch pale leaden countenances,
such a total loss of strength, and such frequent and acute inter-
nal pains, as have suffi Usntly proved a diseased state of some of
the viscera, and which have soon been followed by a painful
death.

If extirpation ever bids fair for the cure of a cancer, it seems

scrotum, which, when they grew troublesome, he picked off; but he had
never perceived any sore, ulceration, or considerable hardness in that part.

Mr. Pott has observed that he never saw the disease under the age of pu-
berty ; but since the publication of his treatise I saw it in an infant under
<jight years of ;.ge, who was brought into St. Bartholomew's hospital, and was
an apprentice to a chimney-sweeper. I showed it to Mr. Pott, who acknow-
ledged it to be the true disease, and that he had not before seen it in sc
^onnga subject. It had infected all the lower part of the scrotum ; but as
the testishad not imbibed the poison, the diseased part being removed, the
uound healed, and the boy was discharged perfectly well. E.

CANCER SCROTI. 293

to be in this case; but then the operation should be immediate,
and before the habit is tainted. The disease, in these people,
seems to derive its origin from a lodgement of soot in the ruga? of
(he scrotum, and at first not to be a disease of the habit. In other
cases of a cancerous nature, in which the habit is too frequently-
concerned, we have not often so fair a prospect of success by the
removal of the distempered part; and are obliged to be content
with means, which I wish I could say were truly palliative. But
here the subjects are young, in general in good health, (at least at
first,) the disease brought on them by their occupation, and in all
probability local; which last circumstance may, I think, be fairly
presumed from its always seizing the same part: all this makes it
at first) a very different case from a cancer which appears in an
elderly man, whose fluids are become acrimonious from time, as
well as other causes; or from the same kind of complaint in wo-
men who have ceased to menstruate. But be all this as it may,
the scrotum is no vital organ, nor can the loss of a part of it ever
be atlendcd with any the smallest degree of inconvenience; and if
a life can be preserved- by the removal of all that portion that is
distempered, it will be a very good and easy composition; for
when the disease has got head, it is rapid in its progress, painful
in all its attacks, and most certainly destructive in its event. b

i, Tills species of cancer, which Mr. Pott has so accurately described, ap-
pears to be produced by some peculiar acrimonious quality in soot, when in-
corporated and fermenting with the secretions on the skin of some persons,
whose constitutions are disposed to undergo a certain change, or receive a
new modification of their inherent properties. As chimney-sweepers are in
the constant habit of being in contact with soot, it follows that they must be
most liable to a disease which is evidently caused by it ; but, as was before
observed, those only whose constitutions are disposed to receive the poison
are infected ; not one in many hundreds being injured by it. Mr. Potts< em-
ed to suppose that this species of cancer was peculiar to chimney-sweepers;
but I have strong grounds for thinking that he was mistaken in that idta.
There are instances, though I believe them to be vers rare, (as I know no one,
either author or practitioner, who has noticed them); yet there are instances
of other persons being infected by the contact or effluvia of soot ; and as a
caution for every one to be careful of handling it, or in any way being expo-
sed to its action, I will relate the case of a man who was attacked with this
dreadful disease to a most lamentable degree, aid was brought into the hos-

!-•. together \\ i ; h ihr

294 CANCER SCROTI.

glands in the groin, were included in a large phagedenic ulcer. The nature
of the disc ase was so marked and evident, that I took for granted that he was
a chimney-sweeper, and was much surprised to find that his business was
quite of another kind. I could not, however, avoid repeatedly asking him
if he had ever had any thing to do with sweeping chimneys : he assured me
not. Some time after he told me, that on considering the questions which
I hud so often urged, he recollected, that not many years before he had lodg-
ed at the house of a chimney-sweeper, in the apartments of which soot-bags
and soot were deposited. He did not appear very accurate in his account,
but thought on recollection that the complaint began in the scrotum soon af-
ter he left the chimney-sweeper's house. This goes nearly to prove that
soot in substance, or perhaps the volatile parts of it, have the power of pro-
ducing the disease ; and not any thing peculiar to the occupation or manner
of life to which chimney-sweepers are subject. Probably the man's body,
or his linen, were liable to be daubed with soot, or the dust arising from it;
and the scrotum was first affected, as it is among chimney-sweepers, for the
reason before given ; that of the moist rugae retaining the poison more readi-
ly than other parts.

As a further caution to "persons who may be employed in making use of
.soot, to be careful in washing and cleansing themselves, I will mention an-
other case which I met with, and which in my mind goes pretty clearly to
ascertain the fact, that soot is of a dangerous nature, and capable of produ-
cing this disease in other people, as well as chimney sweepers.

Allan Spragg, aged 49, came into St. Bartholomew's hospital, on account
of a large cancerous sore, which reached from the bend of the wrist to the
knuckles, occupying almost the whole of the back of the left hand. He had
been under the care of many persons, and various applications and internal
medicines had been given. The circumference of the sore rose in large ul
coated tumors, and seemed inclined to spread. In some parts of the middle
it appeared in a healing state — in other parts ulcerated ; but he said differ-
ent parts of it had often healed and broke out again, as we afterward found
it inclined to do. There was an indescribable something in the appearance
of the complaint, which put me in mind of the sooty-wart, or chimney-sweep-
ers' cancer ; for there is a peculiar appearance in that disease, to the eye of
any one who has paid attention to it, very different from any other cancer
ous sore. This led me to make a particular inquiry into this person's life
and occupation. He said he was a gardener; that about five years before
(in 1800) he was employed in a garden at Lowlayton, in Essex; that in
the spring of that year h was engaged about two hours every morning t»
strew soot on the ground, round the young and tender plants, to preserve
them from the slugs ; that he carried the soot in an old garden-pot, which
hung on his left hand by a handle over the top, while he strewed it with the
right. About tin* time he conceived the wart commenced near the knuc-
kles and continued not very troublesome all that year ; the next spring he
wns again employed to distribute soot; the wart was then increased and
Ulcerated, and continued growing worse all that year. The spring follow-

CANCER SCROTI. *9o

mg he again used soot in the same manner : the sore then spread, and grew
larger, which made work of any kind very difficult to him.

It is to be remarked that the right hand which strewed the soot was unaf-
fected. Probably from that action it got rid of the effect of the effluvia ; but
the left, being two hours exposed to the vapours or dust arising from die
soot, as it was continually stirred up, a lodgement of it was probably made on
the thin skin at the back of the hand. The man said he always washed his
hands before he came in to breakfast, but such persons are not always very
accurate in their ablutions.

For the last two years he had not used soot, but the sore continued to
spread rapidly; however he kept on working till October, 1*04, when he
was incapable of using the hand. December 27th, he came into the hospital.
The various means which were used, both internally and externally, to en-
deavour to stop the progress of, and cure the disease, it is unnecessary to de-
tail in this place, as unfortunately none of them proved of any very materia
service; for though sometimes one part appeared healing, another continued
to open and spread. In rerum naturd there may probably exist a cure for
this dreadful malady, but it has hitherto escaped our researches.

Poor Allan left the hospital several times, and put himself under the care
of some soi-disans doctors, both male and female, who promised to cure him,
but always returned with the disease worse and worse, till at last he submit-
ted to amputation, after which the excruciating pains which he had suffered
soon left him, and as a pretty clear proof of the locality of the disease, and
that it was not constitutional, the wound from the operation healed kindly,
and he got perfectly well. E.

OBSERVATIONS

MORTIFICATION OF THE TOES AND FEET.

The powers and virtues of the Peruvian bark are known to
almost every practitioner in physic and surgery. Among the
many cases in which its merit is particularly and justly celebrated,
are the distempers called gangrene and mortification; its general
power of stopping the one, and resisting the other, have made no
inconsiderable addition to the success of the chirurgic art: but still
there is a particular species even of these, in which this noble
medicine most frequently fails; I mean that particular kind,
which, beginning at the extremity of one or more of the small toes,
does, in more or less time, pass on to the foot and ankle, and
sometimes to a part of the leg, and, in spite of all the aid of physic
and surgery, most commonly destroys the patient.

It is very unlike to the mortification from inflammation, to that
from external cold, from ligature, or bandage, or to that which
proceeds from any known and visible cause, and this as well in
its attack as in its process. In some few instances it makes its
appearance with little or no pain; but in by much the majority of
these cases, the patients feel great uneasiness through the whole
foot and joint of the ankle, particularly in the night, even before
these parts show any mark of distemper, or before there is any
other than a small discoloured spot on the end of one of the little
foes.

vol. it, p p

298 ON THE MORTIFICATION

It generally makes its first appearance on the inside, or at the
extremity of one of the smaller toes, by a small, black, or bluish
spot: from this spot the cuticle is always found to be detached,
and the skin under it to be of a dark red colour.

If the patient has very lately cut his nails, or corn, it is most
frequently, though very unjustly, set to the account of such opera-
tion.

Its progress in different subjects, and under different circum-
stances, is different; in some it is slow, and long in passing from
toe to toe, and from thence to the foot and ankle; in others its
progress is rapid, and horridly painful. It generally begins on the
inside of each small toe, before it is visible either on its under or
upper part; and when it makes its attack on the foot, the upper
part of it first shows its distempered state, by tumefaction, change
of colour, and sometimes by vesication; but wherever it is, one
of the first marks of it is a separation or detachment of the
cuticle.

Each sex is liable to it; but for one female in whom I have met
with it, I think I may say, that I have seen it in at least twenty
males. I think also that I have much more often found it in the
rich and voluptuous, than in the labouring poor; more often in
great eaters, than free drinkers. It frequently happens to persons
advanced in life, but is by no means peculiar to old age. It is not,
in general, preceded or accompanied by apparent distempera-
ture cither of the part, or of the habit. I do not know any par-
ticular kind of constitution which is more liable to it than an-
other; but, as far as my observation goes, I think that I have most
frequently observed it to attack those who have been subject to
flying, uncertain pains in their feet, which they have called gouty,
and but seldom in those who have been accustomed to have the
gout regularly and fairly. It has, by some, been supposed to arise
from an ossification of vessels; but for this opinion I never could
find any foundation but mere conjecture.

The common method of treating this distemper is, by spirituous
fomentations, cataplasms actually and potentially warm, by dress-
ings of the digestive kind, as they are called, animated with warm,
pungent oils and balsams, &c; and, internally, by the Peruvian
bark.

OF THE TOES AND FEET. 299

I wish I could say that this, which, with little alteration, has
been the general practice, had been most frequently, or even often
successful; but I am, from long and repeated experience, obliged
to say, that it has not.

I am sensible that many of my readers will be surprised at my
affirming, that the Peruvian bark will not stop a mortification, a
distemper in which, for some years, it has been regarded as spe-
cific; but I must beg not to be misunderstood; I mean to confine
my observation and my objection to this particular species of mor-
tification, which I regard as being sui generis; and under this re-
striction I must repeat, that I have seldom, if ever, seen the baric
successful: in all other cases, wherein it is used or recommended,
no man has a' higher opinion of it; but in this I cannot give it a
praise which it does not deserve.

I believe I may venture to say, that I have tried it as fairly, as
fully, and as variously, as any man has or can: I have given it in
the largest quantity, at the shortest intervals, and for the longest
possible space; that is, as long as the patient's life would permit.
I have given it by itself, in decoction, extract, and substance. I
have combined all these together. I have joined it with nitre,
sal. absynth., with snake-root, with confect. cardiac, with vola-
tile salts, and with musk, as different circumstances seemed to re-
quire or admit. I have used it as fomentation, as poultice, as
dressing. I have assisted it with every thing which has been
usually thought capable of procuring, or assisting digestion: still
the distemper has continued its ' course, perhaps a little more
slowly, but still it has ended in death.

I am sorry to rob one of our great medicines of any part of its
supposed merit; but as, on the one hand, its claim, in fliis in-
stance, is unjust, and as, on the other, I hope to add as much to
the character of another, the res medica will be no sufferer.

Sometime ago, I had a patient labouring under this complaint,
who, from antipathy, obstinacy, or some other cause, could not be
prevailed on to take bark in any form whatever. I made use of
every argument, but to no purpose. Fomentation, poultice, and
the usual dressings were applied in the usual manner; the disease
advanced, some days more, some days less, and, at the end of a
fortnight, the small toes were all completely mortified, the great

300 ON THE MORTIFICATION

one become blackish, the foot much swollen, altered in colour, and
the disease seeming to advance with such hasty strides, that I sup-
posed a very few days would determine the event. The pain in
the foot and ankle was so great, and so continual, as totally to
deprive the patient of sleep. On this account, and merely to pro-
cure some remission, I gave two grains of opium at night, which
not having the desired effect, I repeated it in the morning. Finding,
during the following day, some advantage, I repeated the same
dose night and morning, for three days; at the end of which time the
patient became quite easy, and the appearances on the foot and ankle
were visibly more favourable. Encouraged by this, I increased the
quantity of the medicine, giving one grain every three or four hours,
taking care to watch its narcotic effect, and to keep the belly empty
by clysters. In nine days from (he first administration of the opium,
all the tumefaction of the foot and ankle totally subsided, the skin
recovered its natural colour, and all the mortified parts plainly
began to separate; in another week they were all loose, and casting
off, the matter was good, and the incarnation florid. During the
whole of this time, I continued the use of the opium, varying its
quantity as circumstances required, but never gave less than three
or four grains in twenty-four hours.

When the sloughs were all cast off, the bones separated, and
I had only a clean sore to dress and heal, I gradually left off the
medicine.

I am very willing to acknowledge, that however well pleased I
might be with the event of this case, yet I really regarded it as
•accidental; so much so, that having very soon after another oppor-
tunity, I did not care to trust to opium alone, but joined the bark
with it? The event was equally fortunate. But although I had
joined the cortex with the extractum thebaicum, and did therefore
attribute the success to their united powers, yet the effect was so
very unlike to what I had ever seen from the bark without opium,
that I could not avoid seriously, and often, reflecting on it, and
determining to use it by itself, whenever another opportunity
should offer. I did so, and succeeded in the same happy
manner, though under the very disagreeable circumstances of
seventy years of age, a broken, distempered constitution, and the
disease making a hasty progress.

OF THE TOES AND FEET. 301

To relate cases which are nearly, or at least materially similar,
is of no use: I shall therefore only say, that every opportunity,
which I have had since of making the experiment, has still more
and more convinced me of the great value and utility of this medi-
cine, and of its power of rescuing from destruction persons under
this affliction.

I cannot say that it has never failed me: it certainly has; but
then it has been under such circumstances, as I think would fairly
account for the failure.

I should be exceedingly sorry to be misunderstood; I should be
still more so to mislead any body; and therefore I beg it may be
noticed, that I do not propose (he extractum thebaicum, in this
case, as an universal, infallible specific. I know, from experience,
that it is not: but as I also know, from repeated experience, that it
will, under proper management and direction, do more than any,
or than all other medicines; and that I have, by means of it, saved
some lives, which, I am very sure, would, under the common and
most approved method of treatment, without it, have been lost —
I could not answer to myself the not communicating what I had
observed.

If this was an experiment, in which the life, or limb, or health
of the patient was in any degree endangered, or by which the per-
son, on whom it may be tried, could in any degree be injured, I
should have withheld what I now publish, until a greater length of
time, and more experience, had rendered it still more, absolutely
certain; and I should have thought myself strictly vindicable in so
doing: but as this is a medicine, whose general effects are well
known, and which is at the same time so capable of direction and
management, that it is almost impossible for any person, who
deserves to be trusted with medicine at all, to do any material harm
with it, I thought it would be wrong and unjust to conceal what
had occurred to me, lest I might thereby deprive the afflicted of an
assistance, which, I verily believe, is not to be obtained from any
other quarter.

In short, from what I have seen and done, I am perfectly con-
vinced, that, by its means, and by its means solely, I have saved
lives which, without it, must have been lost.

If it preserves a few of those, who are so unfortunate as to labour

302 ON THE MORTIFICATION

under this nasty, painful, lingering, and destructive disorder, to
which we are all liable, and which has hitherto, most frequently,
foiled all attempts of art, I shall be sincerely glad to have con-
tributed to so good an end: if it should prove in other hands as
successful as it has with me, I shall be still more so: but on the
other hand, if after several times giving me reason to believe
and hope that it would prove an instrument for the preservation of
many, it should, upon more repeated trial, be found to fail, I shall
be sorry for the event, but shall still think, that I did right in com-
municating what I had seen, and thereby endeavouring to be useful
to mankind.

Hoc opus, hoc sludium, parvi propercmus ct ampli,
Si patrioz volumus, si nobis vivere cari.

If I am right in my conjecture concerning this hazardous and
destructive malady; and if the method which I have proposed and
practised, should prove as successful in the hands of others, as it
has in mine, I cannot help thinking, that the external or chirurgic
treatment of the disorder might be amended; that is, might be
made to coincide more than it does at present with such sooth-
ing kind of plan.

Since I have had reason to embrace this opinion, and to act in
conformity to it, I have found more advantage from frequently
soaking the foot and ankle in warm milk, than from any spiritu-
ous or aromatic fomentations whatever; that is, I have found the
one more capable of alleviating the pain, which such patients al-
most always feel, than the other; which circumstance I regard
as a very material one. Pain is always an evil; but in this par-
ticular case I look upon it as being singularly so. Whatever
heats, irritates, stimulates, or gives uneasiness, appears to me al-
ways to increase the disorder, and to add to the rapidity of its
progress; and, on the contrary, I have always found that what-
ever tended merely "to calm, to appease, and to relax, at least re-
tarded the mischief, if it did no more.

The whole plan of the chirurgic treatment of this disease is
founded on a general idea of warming, invigorating, stimulating,
and resisting putrefaction; and the means generally made use of

OF THE TOES AND FEET. 303

are very proper for such purpose; but I must own that I think
the purpose, or intention, to be improper.

Upon this principle, the old theriaca Londinensis, and the pre-
sent cataplasma e Cymino, have been, and still are so freely used
on this occasion. A composition of this kind, if it does any thing,
must heat and stimulate, and it is by heating and stimulating the
skin, to which it is applied, that it so frequently does that mis-
chief which 1 am confident it often does, though such mischief is
set to the account of the nature of the disorder. Cases exactly
similar, in all circumstances, are not to be met with every day;
but I am from experience convinced, that of two, as nearly simi-
lar as may be, in point of pain, if the one be treated in the usual
manner, with a warm, stimulating cataplasm, and the other only
with a poultice made of the fine farina seminis lini, in boiling
milk or water, mixed with ung. sambuc. or fresh butter, that the
pain, and the progress of the distemper, will be much greater
and quicker in the former than in the latter.

When the black or mortified spot has fairly made its appear-
ance on one or more of the toes, it is the general practice to scarify
or cut into such altered part with the point of a knife or lancet.
If this incision be made merely to learn whether the part be mor-
tified or not, it is altogether unnecessary: the detachment of the
cuticle, and the colour of the skin, render that a decided point.
If it be not made quite through the eschar, it can serve no pur-
pose at all; if it be made quite through, as there is no confined
fluid to give discharge to, it can only serve to convey such medi-
cines as may be applied for the purpose of procuring digestion to
parts capable of feeling their influence, and on this account they
are supposed to be beneficial, and therefore right.

When the upper part of the foot begins to part with its cuticle,
and to change colour, it is a practice with many to scarify imme-
diately; here, as in the preceding instance, if the scarifications be
too superficial, they must be useless; if they be so deep, as to cause
a slight haemorrhage, and to reach the parts which have not yet
lost their sensibility, they must do what indeed they are generally
intended to do, that is, give the medicines which shall be applied,
an opportunity of acting on such parts.

The medicines most frequently made use of for this purpose

304 [" ON THE MORTIFICATION

are, like tire theriaca, chosen for this supposed activity; and con-
sist of the warm, pungent oils and balsams, whose action must
necessarily be to stimulate and irritate. From these qualities
they most frequently excite pain, which, according to my idea of
the disease, is diametrically opposite to the proper curative inten-
tion; and this I am convinced of from repeated experience.

The dressings cannot consist of materials which are too soft
and lenient; nor are any scarifications necessary for their applica-
tion. But I would go further and say, that scarifications are not
only useless, but, in my opinion, prejudicial, by exciting pain, the
great, and chiefly to be dreaded, evil in this complaint. The
poultice should be also soft, smooth, and unirritating; its intention
should be merely to soften and relax; it should comprehend the
whole foot, ankle, and part of the leg; and should always be so
moist or greasy, as not to be likely to become at all dry or hard
between one dressing and another.

I will trouble the reader with only one remark more.
When the toes are, to all appearance, perfectly mortified, and
seem so loose as to be capable of being easily taken away, it is, in
general, thought right to remove them. However rotten and loose
they may seem to be, or really are, yet while they hold on, they
hold by something which is still endued with sensation, as may
always be known, if they be bent back or twisted with any de-
gree of violence.

I will not enter into a dispute about the sensibility or insensibi-
lity of ligaments, nor undertake to determine whether thay be liga-
ments, or any other kind of parts which still maintain the connex-
ion of the toes with their own respective joints, or with the me-
tatarsal bones; it is sufficient for me to know, and to inform the
young practitioner, that however loose (hey may seem, yet if they
be violently twisted off, or the parts by which they hang be divid-
ed, a very considerable degree of pain will most commonly attend
such operation, which therefore had much better be avoided; and
that I seen this very pain, thus produced, bring on fresh mischief,
and that of the gangrenous kind.

If the patient does well, these parts will certainly drop off: if
he does not, no good can arise from removing them.

REMARKS

ON THE

NECESSITY AND PROPRIETY

OF THE

OPERATION OF AMPUTATION

IN CERTAIN CASES,
DER CERTAIN CIRCUMSTANCES.

vol. ii. q q

REMARKS

OPERATION OF AMPUTATION.

No man, however slightly acquainted with the history of Sur-
gery can have the smallest doubt of the superiority which its pre-
sent state justly claims over that of our predecessors, especially
over that of our more remote ones.

The surgery of the last century, and even of some part of this,
was coarse and cruel in its operative part, painful and tedious in
what is generally called the curative. A multiplicity of heavy
unmanageable instruments characterised the former, and a variety
of irritating applications the latter. By means of the one, many
operations were rendered much more terrible to bear, as well as
more hazardous in the event, than they ought to have been; while
long suffering and tedious confinement became the necessary con-
sequences of the use of the other.

To simplify the art has been the aim of all the best practition-
ers of later times, and to this they owe both their success and
their reputation; by this they have reduced our instruments to a
small number, and have rendered those which are now used much
more manageable; upon the same plan, they have discharged a
farrago of external applications, the majority of which were either
useless or mischievous. A prosecution of the same method will.

508 REMARKS ON AMPUTATION.

I make no doubt, produce greater improvements, but still opera-
tions will for ever remain unavoidable in particular circum-
stances, and some diseases will still sometimes require applica-
tions which must produce uneasiness: to render these as seldom
necessary, and as little painful as possible, should be the business
of every practitioner, and this is all that art can do, or that should
be expected from it. The boast of universal specifics, of reme-
dies infallibly preventive of diseases, and of means whereby
chirurgical operations may be rendered totally unnecessary, is the
language of quackery, and not of science.

The amputation of a limb is an operation terrible to bear, hor-
rid to see, and must leave the person on whom it has been per-
formed in a mutilated, imperfect state; but still it is one of those
which becomes, in certain circumstances, absolutely and indis-
pensably necessary.

To those who are well acquainted with surgery, it must ap-
pear needless to have said this; they well know the truth of it:
but as they who have not had sufficient opportunity of obtaining
practical information, may be misled by a contrary doctrine,
when boldly advanced; and as they who are realty well informed,
may, under certain circumstances, be deterred from acting up to
their knowledge, I have thought that 1 should not absolutely mis-
spend my time, nor do mankind a disservice, if I took this oppor-
tunity of giving the subject a little consideration.

I am the more inclined to do this for three reasons:

1st. Because I am satisfied that the propriety of amputations
in certain cases, stands upon as fixed and as rational principles as
any part of surgery.

2d. Because a contrary doctrine has within a few years been
boldly and industriously propagated, not without some very in-
decent, as well as untrue reflections, on the profession in general,
and on those who have the care of hospitals in particular: and,

3dly. Because I am convinced that such doctrine has been em-
ployed to the prejudice of mankind, by covering ignorance and
timidity, and also for serving the base purpose of malevolence.

" JVe occidisse nisi servasset," is, under certain limitations, a
very just and prudent maxim, but taken at large may be produc-

REMARKS ON AMPUTATION.

300

live of much mischief. Mankind are rather too apt to form their
opinion from events only; success with many constitutes propriety,
and the failure of it is often very unjustly set to the account of mis-
conduct, or of want of knowledge. A young practitioner at a
distance from assistance, and thereby deprived of that support,
may be afraid to put his character to hazard, by. acting in such
manner, as although it might justly entitle him to success, yet
cannot command it. He may understand his art, but art is not
infallible. He may be a very excellent surgeon, and yet be afraid
to encounter the prejudices of some, or the malevolence of others.
A few years ago a book was published professedly to oppose and
condemn the practice of amputation, in all cases whatever, and
almost without exception. The book was written by a Mr. Bil-
guer, a surgeon in the Prussian service. Mr. Tissot wrote some
Annotations on it, and a Preface, announcing its great and won-
derful merit and utility; and the whole was translated into Eng-
lish, and dedicated to Sir John Pringle. Both the book and the
Annotations contain some very extraordinary doctrines and asser-
tions, neither of which it is my intention to criticise in this place.
They who read the work, and understand the subject, will, I
verily believe, have but one opiuion. The writer, as well as the
annotator, may have meant well; but certain I am, if their^pinions
were generally followed, mankind would be great sufferers. The
particular cases in which the operation of amputation is totally
and absolutely unnecessary, and therefore wrong, are in Lis own
words, or at least in those of his translator, as follow: —

" 1st. A mortification which spreads until it reaches the bone.
« 2dly. Any limb so greatly hurt, whether by fracture or dilace-
" ration, that there is room to dread the most fatal conse-

" quenccs.

" 3dly. A violent contusion of the soft parts, which has at the

" same time shattered the bones.

» 4thly. Wounds of the larger vessels, which cc '.vey blood into

« the limb, either as the only way of stoppingthe haemorrhage, or

; through apprehension it should perish for want of nourishment.

" 5thlv. An incurable caries of the bone."

310 REMARKS ON AMPUTATION.

Ill the first of these the art of surgery has very little to do, ex-
cept the mere sawing the bones through: nature, if the patient
lives, will in general do all the rest, and will remove the limb,
whether the surgeon may choose it or not. In the 2d, 3d, and
4th, what the writer has asserted is so repugnant to the universal
opinion of all the ablest and best practitioners, to common sense,
and to constant experience; and his doctrine would, if followed,
be productive of so much mischief to mankind, that I cannot help
bearing my testimony against it. But as flat contradictions have
no more authority than positive assertions, I take this opportunity
of giving my reasons for a different opinion at large.

The cases in which, under certain circumstances, amputation
may become necessary for the preservation of the patient's life,
are several; but I will confine myself to four.

These are: 1. A compound fracture.

2. Some kind of scrofulous joints.

3. Some kind of aneurisms.

4. A caries of the whole substance of the bone or bones com-
posing a limb.

In all, and each of which, it may, and does sometimes so hap-
pen, that the patient's life can be only preserved by the loss of
his limb. This doctrine is very opposite to that of the book just
cited; but if it be consonant to truth and experience, it matters not
from whom it may differ.

In compound fractures, there are three points of time in which
the operation of amputation may become necessary. The first of
these is immediately, or as soon as may be, after the receipt of the
injury. The second is, when the bones continue for a great
length of time without any disposition to unite; and the discharge
from the wound has been so long and is so large, that the patient's
strength fails, and general symptoms foreboding dissolution come
on. And the third is, when a mortification shall have taken such
complete possession of the soft parts of the inferior part of the
limb, quite down to the bone, that, upon separation of such parts,
the bone or bones shall be left bare in the inter-space.

The first and second of these are matters of very serious consi-
deration. The third hardly requires any.

When a compound fracture is caused by the passage of a very

REMARKS ON AMPUTATION. Oil

heavy body over a limb, such, for instance, as the broad wheel of
a wagon, or a loaded cart, or by the fall of a very ponderous body
on it, or by a cannon shot, or by any other means so violent as to
break the bones into many fragments, and so to tear, bruise, and
wound the soft parts, that there shall be good reason to fear that
there will not be vessels sufficient to carry on the circulation with
the parts below the fracture, it becomes a matter of the most seri-
ous consideration, whether an attempt to save such person's limb
will not be the occasion of the loss of his life: this consideration
must be before any degree of inflammation has seized the part,
and therefore must be immediately after the accident.

When inflammation, irritation, and tension have taken place,
and when the air admitted freely into the tela cellulosa has begun
to exert its pernicious influence, it is too late: an operation then,
instead of being beneficial, would prove destructive.

The necessity of immediate, or very early decision in this case,
arising from the circumstances already mentioned, make this a
very delicate part of practice: for however pressing the case may
seem to the surgeon to be, it will not iiv general appear in the same
light to the patient, to the relations, or to by-standers; they will
be inclined to regard the proposition as arising from ignorance
how to treat the case properly, or from an inclination to save trou-
ble; or perhaps from a still worse motive, a desire to operate; and
it will often require more firmness on the part of the practitioner,
and more resignation and confidence on the part of the patient,
than is generally met with, to submit to such a severe operation, in
such a seeming hurry, and upon so little apparent deliberation; and
yet it often happens, that the suffering this point of time to pass,
decides the patient's fate. I must repeat, that this necessity of
early decision, arises from the very just dread of the ill effects of
a greatly obstructed circulation, owing to a large destruction of ves-
sels: these, added to those arising from pain, irritation, and the
admission of air, often produce a high fever, and intense inflam-
mation, ending, and that very shortly, in gangrene, mortification,
and death. That this is no exaggeration, melancholy and fre-
quent experience evinces, even in these whose constitutions pre-
vious to the accident were in good order; but much more in those
who had been heated bv violent exercise, nr labour, or liquor,

312 REMARKS ON AMPUTATION.

who have led very debauched and intemperate lives, or who have
habits naturally inflammable and irritable.

This may be, and often is the case, when the fracture happens
to the middle part of the bones, at the greatest possible distance
from the extremities; but is much more likely to happen, and in-
deed much more frequently is the case, when any of the large
joints are concerned: the circumsiances of broken bones in these
parts, and of torn, bruised, and wounded ligaments, to say nothing
of the admission of air into joints, are dreadful additions to the
hazard, and demand a speedy decision, as they are productive of
the worst consequences in the shortest space of time; and there-
fore, that, in many of these cases, a determination for or against
amputation is really a determination for or against the patient's
existence, is a truth of which I am as well satisfied, as I am, or
can be, of any truth whatever.

That it would have been impossible to have saved some limbs
which have been cut off, no man will pretend to say; no man that
knows any thing of the matter can say it:, but this does not at all
alter the consideration, or render the practice injudicious or blama-
ble, the question really standing thus: — Do not the majority of
those whose misfortune it is to get into the just mentioned hazard-
ous circumstances, and on whom the operation of amputation is
not performed, perish, and that by means of their wounds? Or,
to put the same question into other words, have not many lives
been preserved by means of amputation, which, from the same
circumstances, would otherwise moss, probably have been lost?j It
is not for me, especially after what I have said, to determine it: it
is not indeed for any one man to do it. I therefore appeal to all
the best practitioners, to those who have seen the most of these
accidents, for the truth of the assertion.

When a judicious man says that a limb ought to be removed, it
is not to be supposed that he means to say, that it is absolutely
impossible, at all events, that such limb can be saved, nor that
such patient must infallibly die if the operation be not performed;
no, he only means, that from repeated experience of himself and
others, in all times, it has been found, that the circumstances above
mentioned put the patient's life much more to hazard in an attempt
to save the limb, than the operation does in removing it; and there-

REMARKS ON AMPUTATION. 313

fore that humanity as well as judgment determine for the latter.
On the other hand, it must be allowed, that, from some of the worst
of these cases, some have had the good fortune to escape; but
escapes they so truly are, that I make no scruple to affirm, that in
certain cases and circumstances, a determination not to amputate,
is a determination much more unfavourable and hazardous to the
patient, than that for amputation can be.

It is, I think, impossible for any person, who has either sense or
candour, so to misconstrue what I have said, as to imagine that I
would recommend the amputation of the majority of limbs which
have suffered a compound fracture: such conduct would be as inju-
dicious as it would be cruel. My meaning is, that the operation
should be limited and confined to certain cases and circumstances
already mentioned, and that under them it is not only proper, but
necessary.

Pressing and urgent as the state of a compound fracture may be
at this first point of time, still it will be a matter of choice whether
the limb shall be removed or not. Very serious deliberation may
be required, added to all the judgment and experience of the most
able practitioner, to determine what may be most for the patient's
safety; but at the second period which I have mentioned, the opera-
tion ceases to be a matter of choice, it must be submitted to, or
the patient must die.

The most unpromising appearances at first do not necessarily or
constantly end unfortunately. Every body conversant with busi-
ness of this kind, knows, that sometimes, after the most threatening
first symptoms, after considerable length of time, great discharges
of matter, and large exfoliation of bone, it happens, that notwith-
standing all these difficulties and discouragements, success shall
ultimately be obtained, and the patient shall recover his health and
the use of his limb.

But it is also as well known, that after the most judicious treat-
ment through every stage of the disease; after the united efforts of
physic and surgery, it sometimes happens that the sore, instead of
granulating kindly, and contracting daily to a smaller size, shall
remain as large as at first, with a tawny, spongy surface, dis-
charging a large quantity of thin sanies, instead of a small one

yol. ir. r r

814 REMARKS ON AMPUTATION.

of good matter; that the fractured ends of the bones, instead of
tending to exfoliate, or to unite, will remain as perfectly loose and
disunited as at first, while the patient shall lose his sleep, his appe-
tite, and his strength, a symptomatic fever of the hectical kind,
with a quick, small, hard pulse, profuse sweats, and colliquative
purgings, contributing at the same time to bring him to the brink
of the grave, notwithstanding every kind of assistance. In these
circumstances, which are by no means uncommon, if amputation
be not performed, I should be glad to be informed what else can
rescue the patient from destruction.

Let it not, by way of answer, be said, that a more generous plan
of diet should be prescribed; that bark, cordials, anodynes, astrin-
gents, &c. should be taken, because I should be very sorry to have
it supposed that I was either so unknowing or so brutal as to think
of amputation, before every thing of this kind had been fairly and
fully tried, and found ineffectual. I confess that I know of nothing
but the operation which can be attempted; and when, instead of
this, I hear people talk of specific balsams, particular fomenta-
tions, &c. I can only be sorry to find that they are so weak or so
wicked.

I might in this place mention a case which I have twice seen,
which is, that in a compound fracture, which has got well through
the first or inflammatory state, the bones, instead on the one hand
of exfoliating or uniting, or on the other of remaining entirely dis-
united, shall (in particular constitutions) become thoroughly dis-
tempered and enlarged through their whole substance, forming such
a kind of caries as nothing but amputation can cure.

The third and last period which I mentioned regarding compound
fractures, and requiring amputation, is indeed a matter which does
not require much consideration.

Every practitioner knows that sometimes, too often indeed, it
happens that the inflammation consequent upon the injury, instead
of producing abscess and suppuration, tends to gangrene and mor-
tification; the progress of which is often so rapid, as to destroy
the patient in a very short space of time, constituting that very
sort of case in which amputation should have been immediately
performed. But it also sometimes happens, that even this dreadful
and very threatening malady is, by the help of art, put a stop to,

REMARKS ON AMPUTATION. SI 5

but not until it has totally destroyed all the surrounding muscles ;
tendons, and membranes, quite down to the bone, which, upon the
separation of the mortified parts, is left quite bare, and all circulation
between the parts above and those below, is, by this totally cut
off. If it should be said, that merely sawing the bare bones cannot
be called amputating, I will not dispute about the propriety of the
phrase; but only beg leave to observe, that call the operation by
what name you please, the patient loses his limb.

The case is exactly the same, when a mortification, from what-
ever cause, has seized the lower part of a limb, and produced
the same effect. This is the very case which M. Bilguer has
mentioned, of mortification seizing all the parts down to the bone.
Let the cause of the mortification be what it may, if the effect be
the destruction of all the soft parts down to the bone or bones,
either the surgeon must saw them, or they must be left to separate:
in either case the patient loses his limb.

Scrophulous joints, with enlarged carious bones, and distemper-
ed ligaments, make a second kind cf case, in which I have said
that amputation may become absolutely necessary.

There is one circumstance attending this kind of complaint,
which often renders it particularly unpleasant, which is, that the
subjects are most frequently young children, or at least are at so
early an age, as to be incapable of determining for themselves,
which inflicts a very distressing task on their nearest relations.

The common people call these, white swellings; a term not
very inapt, because it conveys an idea of one mark of the distem-
per, which is, that notwithstanding the increase of size in the
joint, the skin is not inflamed, but retains its natural colour.

A history of this kind of disease is a thing very much wanted;"
and I much wish that some man, who has leisure and capacity,
and who has seen business, would undertake it. If I was possess-
ed of the requisite knowledge, it would carry me too far from my
present purpose, which is only to prove that, when it affects the
joints in a certain manner, and to a certain degree, that then the
mischief which it causes is such, that nothing but the removal of
the joint can remedy.

Whoever has had opportunity of seeing much of this disease.

316 REMARKS ON AMPUTATION.

must know, that all the efforts of physic and surgery, by internal
as well as external means, do often prove absolutely ineffectual,
not only to cure, but even to retard the progress of this most ter-
rible malady.

I should be sorry to be misunderstood: I do not mean to say,
lhat this is always, or even most commonly the case, nor that
scrophulous joints are not sometimes relieved, and even cured, by-
means of art. I sincerely wish that they were more frequently,
and that we were possessed of more effectual remedies for this
purpose than we are, or at least than I am acquainted with; but
to the great misfortune of scrophulous people, every man conver-
sant with business knows, that the disease often begins in the very
inmost recesses of the cellular texture of the heads of the btfnes
forming the larger articulations, such as the hip, knee, ankle, and
elbow; that the bones so affected spread gradually, and became
enlarged to a very considerable degree, and carious throughout,
sometimes with great pain and symptomatic fever, sometimes with
very little of either, at least in the beginning; that the cartilages
covering the ends of these bones, and designed for the mobility of
the joints, are totally destroyed; that the epiphyses in many young
subjects are either partially or totally separated from the said bones;
that the ligaments of the joints are so thickened and spoiled by
the distemper, as to loose all natural appearance, and become
quite unfit for all the purposes for which they were intended; that
the parts appointed for the secretion of the synovia become distem-
pered in like manner; that all these together furnish a large quan-
tity of stinking sanious matter, which is discharged either through
artificial openings made for the purpose, or by small ones made by
erosions, and that these openings commonly lead to bones which
are rotten through their whole texture; that, bad as this is, it is
not all, nor the worst; for when the disease is got into this state,
the constant pain, the irritation, and the absorption of poison from
all these distempered parts, bring on a fever of the truly hectical
kind, attended with the most destructive general symptoms, such
as total loss of appetite, rest, and strength, profuse night sweats,
and as profuse purgings, which foil all the efforts of medicine, and
bring the patient to the brink of destruction.

REMARKS ON AMPUTATION. 317

That this is no exaggeration is known to every body.

Now, supposing that the art of surgery, or, what is by many
supposed to be more capable, the art of quackery, could exfoliate
all the bones of a large joint, and restore the internal and medul-
lary parts of it to a sound state; supposing either of them capable
of giving the ligamentous parts a new and healthy structure, and
of re-uniting the loosened epiphyses; I say, supposing, against all
sense, and experience, all this to be practicable, yet it must require
a length of time to accomplish, which such patient's state will not
admit.

The state which I have described is no uncommon one, neither
are the circumstances at all exaggerated; but it is the state of a
person hastening rapidly to destruction, who has no time to lose,
and whose life can be preserved by the removal of the limb
only.

That unless the operation be performed, such patient will perish,
is an incontestible truth; and it is as incontestibly true, that num-
bers in the same circumstances have, by submitting to the opera-
tion, recovered firm and vigorous health, which they have enjoyed
for many years, or even during a long life; and therefore, bad as
this state of things is, and terrible as it must be to loose a limb,
yet if it be thought preferable to parting with life, it is a consola-
tion to have the malady fall on a part where amputation can be
performed, such as the knee, ankle, or wrist, rather than on the
hip, where it cannot, or on the parts about the lumbal vertebra?,
there causing those most dreadful and most destructive distempers,
known e by the names of the Lumbal and Psoas Abscess.

cM. Bilguer and M- Tissot are the only people whom I have^met with, or
heard of, in the profession, who speak of an amputation in the joint of the
hip, as an advisable tiling, or as being preferable to the same operation in
the thigh: the doctrine is so new, and so uncommon, that I must beg leave to
cite the whole passage in their own words, lest my reader should not give
me credit.

" The difficulty attending amputation in the upper parts of the thigh is so
'• considerable that surgeons rather choose to abandon to their fate those
" wounded men, where it appears necessary, than to undertake it; and I own
"I am of the same opinion with them. If, nevertheless, a case occurred,
** wherein the death of the patient was certain, if amputation w«s not per-

%13 REMARKS ON AMPUTATION.

The third kind of disorder which I mentioned as sometimes
producing the necessity of amputation, was the aneurism.

That kind of dilatation of the arterial tube, which is called a
true aneurism, is sometimes found in the middle, sometimes in the
upper part of the thigh, and sometimes in the ham.

The general characteristic marks of this distemper are, a cir-
cumscribed tumor, small at its first appearance, but gradually in-
creasing, and for some length of time having a pulsatory motion
and feel, exactly correspondent with the patient's pulse at the
wrist. This pulsation arising from the motion of the blood from
the heart through the artery, is very easily seen and felt for some

£t formed, I would even prefer taking off the limb at the articulation, rather
'■ than at any other place."

The reason which M. Bilguer gives for this is as extraordinary : " for al-
though it be extremely difficult, yet it prevents the inconveniences and
" accidents which a stump might occasion."

M. Bilguer's annotator seems determined not to be behind hand with his
author, part of his note on the preceding passage being as follows : — " I am
"of opinion that if any one had the misfortune of being reduced to the ne-
" cessity of choosing between amputation at the upper part of the thigh, or
"at the articulation itself, one reason for preferring the latler would be, the
"greater ease there is in stopping the haemorrhage of the crural artery." —
Very extraordinary doctrine this !

That amputation in the joint of the hip is not an impracticable operation
(although it be a dreadful one), I very well know: I cannot say that I have
ever done it, but I have seen it done, and am now very sure I shall never do
it unless it be on a dead body. The parallel which is drawn between this
operation, and that in the joint of the shoulder, will not hold. In the latter
it sometimes happens, that the caries is confined to the head of the os hume-
ri, and that the scapula is perfectly sound and unaffected. In the case of a
carious hip joint, this never is the fact : the acetabulum ischii, and parts
about, are always more or less in the same state, or at least in a distemper-
ed one, and so indeed most frequently are the parts within the pelvis — a
circumstance this of the greatest consequence ; for the power of perform-
ing the operation beyond the seat of the disease, and consequently of to-
tally removing all the distempered parts, is the very decisive circumstance
in favour of amputation every where but in the hips, where (to say nothing
of the horridness of the operation itself) the haemorrhage from a multiplicity
of vessels, some of which are of considerable size, and the immense discharge
which a sore of such dimensions must furnish, the distempered state of
the parts, which cannot by the operation be removed, will render it ineffec-
tual, bold and bloody as it mu6t be.

REMARKS ON AMPUTATION. 319

length of time; but as the tumor becomes gradually larger, the
pulsation in it becomes more and more obscure to the touch; arid
in length of time, when either the artery is dilated to a very con-
siderable size, or has burst, and has shed part of its contents, the
motion becomes, in some cases, so obscure as hardly to be felt at
all, or at least not without very diligent attention. When it has
got into this state, whether it be femoral or poplitean, the lower
part of the limb becomes, by the pressure of the extravasated
blood, and by the obstruction to the circulation through the dilated
artery, considerably loaded and swollen, unfit for use or motion,
and generally very painful.

This is the state, or very nearly the state, in which we most
frequently see it, especially among the labouring poor, who gene-
rally neglect it until it renders them lame and incapable of fol-
lowing their employment; and when it is got into this state it re-
quires immediate attention.

In what manner is this disease, when got to this point, to be
treated? or how is the cure of it to be attempted? for, if some-
thing be not done, the limb will become mortified, and the patient
will perish.

If a man was to answer from theory, he would say, that the
skin is to be divided, the extravasated blood to be cleared away,
and the artery to be tied above and below the dilatation — in short,
that what is called the operation for the aneurism, is to be per-
formed. Sorry I am to find myself obliged to say, that, as far as
my observation and experience go, such operation, however judi-
ciously performed, will not be successful; that is, will not save
the patient's life.

In both these aneurisms, the femoral and the poplitean, it most
frequently happens that the artery is not only dilated and burst,
but it is also distempered some way above the dilatation, particu-
larly in the poplitean. This may very probably be one reason
why the ligature is in general so unsuccessful. The want of col-
lateral branches of sufficient size to carry on the circulation, is
another very powerful impediment. Whether these may be allow-
ed sufficient to frustrate the attempt by the operation, I will not
take upon me to say; but certain I am, that it does not succeed:
I have tried it myself more than once or twice; I have seen it tried

320 REMARKS ON AMPUTATION.

by others; but the event has always been fatal. Excessive pain, a
high degree of symptomatic fever, great tension of the whole limb,
rapidly tending to gangrene, and ending in mortification both up-
wards and downwards, have destroyed all those whom I have
seen, on whom the operation of tying the artery has been prac-
tised.

Nor have I ever seen any other operation than that of amputa-
tion, which has preserved the life of the patient. f

To this, an objection has been made by some, which, if it was
founded in fact, would be a very valid one. It has been said, that
the aneurism in the thigh, or ham, is very seldom the only one
which the patient labours under, and that he most frequently has
the same kind of dilatation either of the aorta, or of some of the
larger vessels within the body. This is urged as a reason against
amputation in this disease; they who maintain this opinion, very
justly observing, that it cannot be of any use to cut off a patient's
leg for a femoral or a poplitean aneurism, who will, in all proba-
bility, be destroyed very soon by the same kind of disease in
another part of him.

If the datum were true, the inference would be just; but it is
not. When I say that it is not true, I mean that it is not con-
stantly or necessarily, or even generally so, as I can from repeated
experience affirm, having several times performed the operation
of amputation for both these, on people who have lived several
years after, without any symptoms of the same kind of disease in

f Since Mr. Pott's time, very considerable improvements have taken place
in the treatment of aneurisms, by which the arguments against the operation
are completely obviated. The late Mr. Hunter suggested the idea of tying
tlie artery above, .and at a distance from the disease itself, by which the bad
and often fatal consequences, which attended the laying open the aneu-
rismal sac, are avoided ; and the anastomozing vessels being found sufficient
to carry on the circulation, completely removes the other objection which
Mr. Pott had conceived. In cases of popliteal aneurisms, it is well known
that the artery has frequently been tied in the thigh with complete success.
And in a case where it was dilated so high up, and so near the groin, that it
v/as impossible to get above it by any ordinary operation, Mr. Abernethy was
compelled to put a ligature on the external iliac within the pelvis, and the
branches of the internal iliac were found sufficient for the nourishment of the
parts below. He has since twice repeated the operation with success. E

REMARKS ON AMPUTATION. 321

amy Other part of them. Indeed, the determination for an opera-
tion when a poplitean aneurism is arrived to the state which I
have just described, is hardly to be called a matter of choice; it
is indeed a matter of absolute necessity. When the swelling from
the extravasated blood is become so large, that the pulsatory feel
of the artery is rendered very obscure, the whole limb below is
exceedingly loaded and swollen, the return of the fluids, both by
the veins and by the lymphatics, so very difficultly executed, that
the patient gets little or no rest from the constant pain; and if
some relief be not obtained, and that speedily, from the art of
surgery, gangrene and mortification are the inevitable conse-
quences.

The means of relief are two — and two only; the operation of
amputation, and that of tying the artery above and below the dis-
eased part.

The operator undoubtedly may make his choice between them,
and follow the dictates of his own judgment and his own expe-
rience; but it must be worth his while to observe, that for the
success of the latter, a free circulation through all the inferior
part of the limb seems to be a very necessary circumstance, and
that when the load, and pressure, and obstruction, are become so
great as even to threaten gangrene and mortification, which is fre-
quently the case, such free circulation is not much to be expect-
ed; but, on the contrary, all the evils arising from a very obstruct-
ed one, and that through distempered parts.

There is another kind of complaint affecting the leg, remove-
able (as far as my experience goes) by amputation only, which is
one reason why I mention it in this place, and to which I might
add another reason, which is, that it either derives its origin from
a burstern artery, or at least is accompanied by it.

I know no name to give it, or under what class to range it, but
will describe it in the best manner I can.

It has its seat in the middle of the calf of the leg, or rather
more toward its upper part, under the gastrocnemius and soleus
muscles: it begins by a small, hard, deep seated swelling, some-
times very painful, sometimes but little so, and only hindering the
patient's exercises; it does not alter the natural colour of the
skin, at least until it has attained a considerable siae; it enlarges

vol. r>. s c

322 REMARKS ON AMPUTATION.

gradually, does not soften as it enlarges, but continues through the
greatest part of it incompressibly hard; and when it is got to a large
size, it seems to contain a fluid which may be felt toward the
bottom, or resting, as it were, on the back part of the bones. If
an opening be made for the discharge of this fluid, it must be
made very deep, and through a strangely distempered mass. ThU
fluid is generally small in quantity, and consists of a sanies mixed
with grumous blood: the discharge of it produces very little dimi-
nution of the tumor; and in a few cases which I have seen, very
high symptoms of irritation and inflammation come on, and, ad-
vancing with great rapidity and most exquisite pain, very soon
destroy the patient, either by the fever, which is high and unre
milting, or by a mortification of the whole leg.

If amputation has not been performed, and the patient dies,
after the tumor has been freely opened, the mortified and putrid
state of the parts prevents all satisfactory examination: but if the
limb be removed without any previous operation, (and which, as
far as my experience goes, is the only way of preserving the pa-
tient's life,) the arteria tibialis postica will be found to be en-
larged, distempered, and burst; the muscles of the calf of the leg
to have been converted into a strangely morbid mass; and the
posterior part of both the tibia and the fibula more or less carious.

The fourth kind of distemper, which I mentioned, as being
sometimes productive of the necessity of amputation, is a caries of
the whole bone or bones forming a limb. By this I would be un-
derstood to mean a caries possessing not only the surface of such
bones, but the whole internal substance, and that from end to end-
This I take to be the very individual case, in which both M. Bil-
guer and M. Tissot have reprobated amputation, and which the
former has mentioned in his fifth article, under the .title of Incu-
rable Caries.

The terms in which M. Bilguer has chosen to express himself,
are rather unfortunate.

After having mentioned three or four different distempers, in
which, in certain cases, and under certain circumstances, ampu-
tation has in general been thought necessary and right, and in
which be is nf a totally different opinion, he adds — An incurable

REMARKS ON AMPUTATION. 323

varies of the bones; which incurable caries he says, ought not to
be amputated, because there is a method of curing it.

If this was merely a blunder in language, and went no farther,
it would be a matter of little importance; but it is a serious piece
of advice, delivered authoritatively, and by a writer who professes
to correct the errors both of his predecessors and contemporaries,
therefore it should not be merely laughed at; and as it is an ad-
vice which is not built on fact, and which is fraught with mischief
to mankind, it ought to be contradicted.

That bones become carious from a variety of causes, such as
the struma, the lues venerea, deep-seated imposthumation, pres-
sure, &c. is well known to every body; and that such carious
bones, properly treated, will exfoliate, and cast off their rotten parts.
is as well known; but when, in some particular habits, whether
scrophulous, scorbutic, or cancerous, the whole substance of the
bone becomes diseased, not only on its surface, but through it^
whole internal medullary texture, and that from end to end, the
same means, be they what they may, will not avail. The use of
the scalper, the raspatory, and the rugine, for the removal of the
diseased surface of bones; of the trephine, for perforating into the
internal texture of carious ones, and of what are called exfoliating
applications, are as well known, I presume, to every practitioner,
as to M. Bilguer; but giving to these all their real or their sup-
posed merit, still I affirm, and that from repeated experience, that
there are cases of caries, in which none of these will succeed,
though ever so judiciously used; that neither by these, nor by any
other means, can an exfoliation be obtained; and that, unless the
whole bone be removed by amputation, the patient will perish.

The metaphor, or simile, by which M. Bilguer endeavours to
illustrate his meaning, is somewhat singular: he says, " The real
" method of doing service to bones consumed by caries, is like
" what happens to boards joined together by nails: if you make
" them excessively dry, the nails fall out of themselves," &c.

Now admitting what I think will not be admitted, that this si-
mile conveys a just and true idea of the manner in which the
rotten parts of bones are separated from the sound, yet it neces-
sarily implies, that in these very bones there are some sound part
or parts, from which the rotten are to be dried off, in order to

324 REMARKS ON AMPUTATION.

loosen the nails, and that the existence of such sound parts is the
sine qua non of the cure.

It may, perhaps, in answer to this, be said, that proper treat-
ment, external and internal, may so alter and correct even the
carious part of a bone, as to render it capable of parting with the
rest, and thereby of becoming sound. I say, admitting this, which
is not in general admissible, yet it sometimes happens, that there
is not time for such experiment, and that, even in very young sub-
jects, the whole habit is, by the rotten bone, so poisoned and
spoiled, that a hectic fever of the putrid kind, with all its train of
horrid symptoms, will, in spite of the efforts of physic and surgery,
in spite of bark and every other specific, in spite of drying, burn-
ing, rasping, and boring, come on, and in a very short space of
time destroy the patient, unless rescued by amputation, which
alone can remove a whole bone.

I have as high an opinion of, and as just a reverence for, both
branches of the medical art, as any man; but I also know, that
they are both in many instances exceedingly unequal to our expec-
tations, and very much limited.

This is a disagreeable and an unfortunate truth, but still it is a
truth, and so much so, that whoever professes a contrary opinion,
is either much deceived himself, or inclined to deceive others.

REMARKS

ON THAT BLIND OF

IPMOT (DBF '3HEI8 M)WMB MSENB8»

WHICH IS FREQUENTLY FOUND TO

ACCOMPANY A CURVATURE OF THE SPINE..

SUPPOSED TO BE CAUSED BY IT.

WITH ITS METHOD OF CURE.

TO

DR. JOHN LEWIS PETIT,

ONE OF THE

Physicians to St: Bartholomew's Hospital

THE

FOLLOWING TRACTS

ARE INSCRIBED,

AS

\ SMALL MARK OF THE GREAT ESTEEM
AND REGARD OF

THE AUTHOR

ON THE

PALSY OF THE LOWER LIMBS, &c.

Among the various objects of Physic and Surgery, there are
unfortunately some, in which all the efforts of both have hitherto
been found absolutely ineffectual, and which therefore have always
made a very disagreeable and melancholy part of practice.

To remove, or even to relieve any of the miseries to which
mankind are liable, is a very satisfactory employment; but to at-
tend on a distemper from its beginning, through a long and pain-
ful course, to its last, fatal period, without even the hope of being
able to do any thing which shall be really serviceable, is, of all
tasks, the most unpleasant.

In such cases, any attempts, however hazardous, provided they
were rational, would be justifiable; certainly then, whatever is not
in itself dangerous, and affords the smallest ray o( hope, ought to
be embraced.

Some little time ago I gave to the public an account of the
success which 1 had seen attend the free use of opium in morti-
fications of the toes and feet; particularly in those which began,
or were attended with, great pain.

In that publication I merely related the fact, as it had happen-
ed under my own eye. I entered into no reasoning about it; nor
did I give to the medicine any greater degree of credit than it
appeared to me to deserve. I did not propose it as a certain
specific, or as a remedy whose success was always and infallibly,
vor.. it. t t

330 ON THE PALSI 01

or indeed even generally to be depended upon. I acknowledged,
that I had several times seen it fail; but as I had also several
times seen it succeed, as I was very sure that no hazard could
possibly attend the experiment; and as the best and most experi-
enced practitioners were obliged to allow, that they were not yet
acquainted with any means whereby they were enabled to prevent
the fatal effects of this most horrid distemper, or even to retard its
daily and painful ravages, I thought it my duty to make known
as early as I could what I had seen, that others might make the
same trial, and thereby propagate the benefit. Had any other
means of relief been known to the faculty, and this had therefore
appeared to me only in the light of another, or a preferable one, I
should certainly have withheld my observations, until more time
had verified and confirmed them, and thereby had proved the su-
perior utility of what I had to propose: but as the fact was direct-
ly the contrary, as opium was the only medicine which I had ever
seen prove really and essentially serviceable; as it had succeeded
so often, and to such a degree, as to satisfy me that much good
might be expected from it; and as I was perfectly sure that not the
least degree of hazard could attend the trial, I thought that such
publication, though early, could not be regarded in any other
light than its true one; I mean that of a request to the profession
in general to repeat the experiment; and that therefore it could
not be justly deemed premature. If upon repeated trial the suc-
cess should not be found equal to what I thought I had good rea-
son to expect, no harm could accrue to the patient: if it should
answer my expectation, it would serve the most valuable of all
purposes.

Since that time I have had the satisfaction of having my opi-
nion confirmed, not only by my own experience, but by the con-
current testimony of several practitioners of eminence in different
parts of the kingdom, who have done me the favour to commu-
nicate to me the result of their experiments: the success of these,
as I expected, from what I had seen, has not been constant, but it
has been so frequent, as to make me very well pleased at having
furnished the hint. I sincerely wish that the good effect was more
general and more certain; but the preservation of even a few, from
a malady, found hitherto to have been inevitably destructive to all

THE LOWER LIMBS. 331

is a matter of some importance, and furnishes no unpleasing
reflection.

I now do the same thing, relative to another disorder, which I
then did with regard to the mortification. I publish an account
of the good success which has attended a particular method of
treating a disease, which has hitherto foiled all the efforts of art;
and as I do it now from the same principle which I did then, viz.
that of inducing others, by making the same experiment, to propa-
gate the benefit, I offer no apology for another early publication.

The disease of which I mean to speak, is generally called a
palsy, as it consists in a total or partial abolition of the power of
using, and sometimes of even moving the lower limbs, in conse-
quence, as is generally supposed, of a curvature of some part of
the spine.

To this distemper both sexes, and all ages, are equally liable.
If the patient be an infant, it becomes an object of constant,
though unavailing distress to its parents; if an adult, he is render-
ed perfectly helpless to himself, and useless to others, which, of
all possible states, is surely the very worst.

When this disease attacks an infant of only a year or two old,
or under, the true cause of it is seldom discovered until some time
after the effect has taken place, at least not by parents and nurses,
who know not where to look for it. The child is said to be un-
commonly backward in the use of his legs, or it is thought to have
received some hurt in its birth.

When it affects a child who is old enough to have already
walked, and who has been able to walk, the loss of the use of his
legs is gradual, though in general not very slow. He at first com-
plains of being very soon tired, is languid, listless, and unwilling
to move much, or at all briskly.: in no great length of time after
this he may be observed frequently to trip, and stumble, although
there be no impediment in his way; and whenever he attempts to
move briskly, he finds that his legs involuntarily cross each other,
by which he is frequently thrown down, and that without stum-
bling; upon endeavouring to stand still and erect, without support,
even for a few minutes, his knees give way and bend forward.
When the distemper is a little further advanced, it will be found

332 ON THE I'ALSr OF

that he cannot, without much difficulty and deliberation, direct
either of his feet precisely to any exact point; and very soon after
this, both thighs and legs lose a good deal of their natural sensi-
bility, and become perfectly useless for all the purposes of loco-
motion. When an adult is the patient, the progress of the dis-
temper is much the same, but rather quicker.

Until the curvature of the spine has been discovered, it gene-
rally passes for a nervous complaint; but when the state of the
back bone has been adverted to, recourse is almost always had to
some previous violence to account for it, some pulling, lifting,
carrying, or drawing a heavy body, which is supposed to have hurt
the back. Jn some few instances, this exertion may have been
such, as might be allowed to have been equal to the effect; but, in
by much the majority, this is so far from being the case, that, if it
be admitted to have had any share at all in it, some predisposing
cause, at least, must be looked for, in which, in my opinion, con-
sists the very essence of the disease.

I have, in compliance with custom, called the disease a palsy;
but it should be observed, that notwithstanding the lower limbs
be rendered almost or totally useless, yet there are some essential
circumstances in which this affection differs from a common ner-
vous palsy; the legs and thighs are, I have just said, rendered un-
fit for all the purposes of locomotion, and do also lose much of
their natural sensibility; but notwithstanding this, they have nei-
ther the flabby feel, which a truly paralytic limb has, nor have
they that seeming looseness at the joints, nor that total incapacity
of resistance, which allows the latter to be twisted in almost all
directions; on the contrary, the joints have frequently a consider-
able degree of stiffness, particularly the ankles, by which stiffness,
the feet of children are generally pointed downward, and they are
prevented from setting them flat upon the ground.

The curvature of the spine, which is supposed to be the cause
of this complaint, varies in situation, extent, and degree, being
either in the neck or back, and sometimes, though very seldom,
in the, upper part of the loins; sometimes comprehending two ver-
tebras only, sometimes three, or more, by which the extent of the
curve becomes necessarily more or less; but whatever may be the
number of vertebrae concerned, or whatever may be the degree or

THE LOWER LIMBS. 333

extent of the curvature, the lower limbs only feel the effect — at
least I have never once seen the arms affected by if.

This effect is also different in different subjects; some are ren-
dered totally and absolutely incapable of walking in any manner,
or with any help, and that very early in the course of the distem-
per; others can make a shift to move about with the help of
crutches, or by grasping their own thighs with their hands; some
can sit in an erect posture, or in a chair, without much trouble or
fatigue, which others are incapable of, at least for any length of
time; some have such a degree of motion in their legs and thighs, as
to enable them to turn and move for their own convenience in bed;
others have not that benefit, and are obliged to lie till moved by
another.

When a naturally weak infant is the subject, and the curvature
is in the vertebrae of the back, it is not infrequently productive of
additional deformity, by gradually rendering the whole back what
is commonly called humped; and by alterations which all the
bones of the thorax sometimes undergo, in consequence of the
flexure and weakness of the spine, by which such persons are
justly said to be shortened in their stature; but in all cases where
this effect has been gradually produced, to whatever degree the
deformity may extend, or however the alteration made in the dis-
position of the ribs and sternum may contribute to such deformity,
yet I think that it will always be found, that the curvature of the
spine appeared first, and, if I may so say, singly, and that all (he
rest was consequential.

While the curvature of the spine remains undiscovered or un-
attended to, the case is generally supposed to be nervous, and me-
dicines so called are most frequently prescribed, together with
warm liniments, embrocations, and blisters, to the parts affected;
and when the true cause is known, recourse is always had to steel
stays, the swing, the screw chair, and other pieces of machinery,
in order to restore the spine to its true and natural figure; but all,
as far as I have observed, to no real or permanent good purpose;
the patient becomes unhealthy, and, languishing for some time
under a variety of complaints, dies in an exhausted, emaciated
state; or, which is still worse, drags on a miserable existence.

334 ON THE PALSY OF

confined to a great chair, or bed, totally deprived of the power of
locomotion, and useless both to himself and others.

This in an infant is most melancholy to see, in an adult most
miserable to endure.

The general health of the patient does not seem at first to be
materially, if at all, affected; but when the disease has been some
time, and the curvature thereby increased, many inconveniences
and complaints come on, such as difficulty in respiration, in-
digestion, pain, and what they all call tightness at the stomach, ob-
stinate constipations, purgings, involuntary flux of urine and
faeces, &c. with the addition of what are called nervous com-
plaints; some of which are caused by the alterations made in the
form of the cavity of the thorax; others seem to arise from im-
pressions made on the abdominal viscera. These are different
both in kind and in degree, in different subjects, but seem to de-
pend very much on the consequences of the curvature — that is, in
naturally infirm children, although the curvature of the dorsal
vertebrae is always the first mark of the distemper, by preceding
every other, yet It is frequently soon followed by such a degree of
deformity of the bones of the trunk, as to be, in conjunction with
the necessary inactivity and confinement of the patient, produc-
tive of all the ills above mentioned.

An affecting instance of this distemper, in the person of a very
promising youth of fourteen years old, with whose family I was
nearly connected, induced me to think more of it than perhaps I
otherwise should have done; and the restoration of the use of his
limbs, immediately after a seemingly accidental abscess near the
part, engaged my attention slill more, and became a matter of
frequent, though not very satisfactory contemplation; I say unsa-
tisfactory, because it served only to increase my doubts, without
leading me toward a solution of them. The more I thought upon
the subject, the more I was inclined to suspect that we had been
misled by appearances, and that a distempered state of the parts
forming, or in the neighbourhood of curvature, preceded, or ac-
companied it: in short, that there was something predisposing,
and that we had most probably mistaken an effect for a cause.

For these suspicions, I had the following reasons, which appear-
ed to me to have some weight:

THE LOWER LIMBS. rJJ5

1. That I had never seen this paralytic effect on the legs from
a malformation of the spine, however crooked such malformation
might have rendered it, or whether such crookedness had been
from time of birth, or had come on at any lime afterwards, during
infancy.

2. That none of those strange twists and deviations, which the
majority of European women get in their shapes, from the very
absurd custom of dressing them in stays during their infancy, and
which put them into all directions but the right, ever caused any
thing of this kind, however great the deformity might be.

3. That the curvature of the spine, which is accompanied by
this affection of the limbs, whatever may be its degree or extent,
is at first almost always the same, that is, it is always from within,
outward, and seldom or never to either side.

4. That since I had been particularly attentive to the disorder,
I had remarked, that neither the degree nor the extent of the curve
made any alteration in the nature or degree of the symptoms at
first, nor for some time after the appearance; or, in other words,
that the smallest curvature, in which only two "or three of the
vertebras were concerned, was always, at first, attended by the same
symptoms as the largest.

5. That although it sometimes happened that a smart blow, or
a violent strain, had immediately preceded the appearance of the
curve, and might be supposed to have given rise to it, yet in many
more adults it happened that no such cause was fairly assignable,
and that they began to stoop, and to faulter in their walking, be-
fore they thought at all of their back, or of any violence offer-
ed to it.

6. That exactly the same symptoms are found in infants, and in
young children, who have not exerted themselves, nor have been
injured by others, as in the adult, who has strained himself, or re-
ceived a blow; and that the case was still the same in those grown
people, who have neither done nor suffered any act of violence.

7. That although it must be allowed, that a dislocation of any
of the vertebra;, would most probably be attended with the samr
kind of symptoms, from the pressure it must make on the spinal
marrow, yet it is also most probable that such symptoms would

336 ON THE PALSY OP

be immediate, and attended with great pain in the part; neither
of which is in general the case here.

These considerations appear to me to have much force; but
what confirmed me in my opinion was the stale of the parts form-
ing the curvature, and which I had several fair opportunities of
examining after death. By these examinations I found, in infants,
in young children, and in those who had been afflicted with the
disorder but a small space of time, that the ligaments connecting
the veriebras, which formed the curve, were in some degree alter-
ed from a natural state, by being somewhat thickened and relaxed,
and that what are called the bodies of those bones, were palpably
spread and enlarged in their texture, just as the bones forming the
articulations are in children who are called rickety. That in
those who had long laboured under the distemper, and in whom
the symptoms were aggravated, whatever might be their age, the
ligaments were still more thickened, relaxed, and altered, the bo-
dies of the bones more spread, more enlarged, and more inclining
to become carious, and the cartilages between the bodies of the
vertebra; much compressed and lessened in size; and that in all
those who had so long laboured under the disease, as to have
been destroyed by it, or by its consequences, the corpora vertebra-
rum were completely carious^ the intervening cartilages totally
destroyed, and a quantity of sanies lodged between the rotten
bones and the membrane investing the spinal marrow."

All these circumstances put together, induced me, as I have al-
ready said, to suspect, that when we attribute the whole of this
mischief to the mere accidental curvature of the spine, in conse-
quence of violence, we mistake an effect for a cause; and that pre-
vious both to the paralytic state of the legs, and to the alteration of
the figure of the back bone, there is a predisposing cause of both,
consisting in a distempered state of the ligaments and bones, where
the curve soon after makes its appearance.

While the subject was fresh in my mind, I happened to be at
Worcester, and in a conversation on it with the late Dr. Cameron

« In the body of a man, who died not long since of this disorder, in its last
and worst state, the bodies of three of the vertebrae were not only quite
carious, but completely separated from all connexions with the ether parts of
the same vertebrae

THE LOWER LIMBS. ' 337

of that place, I mentioned to him my opinion, and my doubts: the
doctor concurred with me, and at the same lime mentioned a cir-
cumstance, which made a strong impression on me. He said,
that he remembered, some years ago, to have noted a passage in
Hippocrates, in which he speaks of a paralysis of the lower limbs
being cured by an abscess in the back or loins; and that taking
the hint from this, he, Dr. Cameron, had, in a case of a palsy of
the legs and thighs, attended by a curvature of the back bone, en-
deavoured to imitate this act of nature, by exciting a discharge
near the part, and that it had proved very advantageous. He also
referred me to Mr. Jeffrys, a surgeon of eminence at Worcester,
for a further account of the same kind of attempt: this gentleman
confirmed what Dr. Cameron had told me, and assured me that
he had found the method equally successful.

It may easily be supposed, that these accounts from gentlemen
of veracity, and of reputation in their profession, still added to my
desire of knowing more on this subject, and determined me to
lose no opportunity of getting information.

The first that offered was in an infant, whose curvature was in
the middle of the neck, and who had lost the use of its legs for
about two or three months. I made an issue by incision on one
side of the projection, and gave strict charge to the mother to
take care that the pea was kept in; the woman, who had no faith
in the remedy, did not take the proper care, and consequently the
discharge was not equal to what it should, and might have been;
but notwithstanding this neglect, at the end of about three weeks
or a month the child was manifestly better, and began to make
use of its legs: it was then seized with the small pox, and died.
The bodies of the vertebrae concerned in the curve were larger
than they should be, and than ihose above and below were, and
their texture much more open and spongy; which difference appear-
ed immediately, before the parts covering them were dissected off.

Some time passed before I had another opportunity. My next
patient was a tall, thin man, about thirty-five years old, who
thought that he had hurt himself by lifting a heavy weight: his iegs
and thighs were cold, and what he called numby, but not abso-
lutely useless: he could with difficulty go about the room with
the help of a pair of crutches, but he could neither rise from his

TOL. II. u u

338 ON THE TALSlf OF

chair, nor get on his crutches, without the assistance of another
person, nor could he, without them, walk at all.

I made a seton on each side of the curve, which was in his
bark, about the middle; and having given his wife directions how
to dress them, I called on him once in three or four days. At the
end of six weeks he had recovered the due degree of sensation in
his limbs, and found much less necessity for the use of his
crutches; he could rise from his bed and from his chair without
assistance; and by means of one crutch, and an underhand stick,
could walk for an hour, or more, without resting, and without fa-
tigue. The setons had now, from not having been properly ma-
naged, worn their way out, and I would have converted each of
them into an issue; but as neither the patient nor his wife had ever
believed that the discharge had had any share in his amendment,
but, on the contrary, that he would have been better without it,
he would not submit to what I proposed, and I left him. At the
distance of about three weeks from the time of my leaving him, I
met him in the street, walking very stoutly, with a common cane,
of which he made little or no use. I asked him what he had
done: he told me that the sores had continued to discharge till
within a few days; but that he had drunk a great deal of comfrey
root, tea, with isinglass, and he supposed that had cured him.

I believe that the cure of this man will, by all who know any
thing of medicine, be thought to be so unlikely to have been ef-
fected by the comfrey and isinglass, that my inference in favour
of the seton will not be thought unreasonable, and that my deter-
mination to prosecute the method, from what I had heard and
seen, was well founded.

Within the course of the last ten or twelve months, I have had
several fair opportunities of doing this, both in St. Bartholomew's
hospital, and out of it; and am yery happy to be able to say, that
it has not only always answered, but in some instances greatly
exceeded my most sanguine expectations, by restoring several
most miserable and totally helpless people to the use of their limbs,
and to a capacity of enjoying life themselves, as well as of being
useful to others.

I have now in the hospital, a boy about twelve years old, whose
case was so truly deplorable, that I made the experiment merely

THE LOWER LIMBS. 359

to avoid the appearance of inhumanity, by discharging him as in-
curable, without trying something. The curvature was in his
back, and consisted of three or four vertebra}; but by means of the
weakness thereby induced, the whole set of dorsal ones had
so universally and gradually given way, that he was exceedingly
deformed both behind and before: he was so absolutely incapable
of motion, that he could neither turn himself, nor sit up in his
bed: his feet were pointed downwards, and his ankles so stiff,
that when he was held up under the arms, the extremities of his
great toes touched the floor, nor could his feet be brought flat to
the ground by any means or force whatever. In short, he was
as perfectly and as totally helpless as can be supposed; and at the
same time in an exceedingly general bad state of health, from dis-
orders of the thoracic and abdominal viscera. In this state he
had been more than a year: it is now about three months since the
caustics were applied; he is become healthy, and free from most
of his general complaints, has the most perfect use of his legs
while he is in bed, can walk without the assistance of any body,
or any thing to hold by; and from his manner of executing this,
will, I make no doubt, in a very short space, recover perfectly the
use of his legs. To this I ought to add, that notwithstanding a
considerable degree of deformity does, and I suppose will, remain,
yet the spine in general is so much strengthened, that he is some
inches taller than he was four months ago.

The remedy for this most dreadful disease consists merely in
procuring a large discharge of matter, by suppuration, from un-
derneath the membrana adiposa on each side of the curvature,
and in maintaining such discharge until the patient shall have per-
fectly recovered the use of his legs. To accomplish this purpose,
I have made use of different means, such as setons, issues made
by incision, and issues made by caustic: and although there be
no very material difference, I do, upon the whole, prefer the last.
A seton is a painful and a nasty thing; besides which, it fre-
quently wears through the skin before the end for which it was
made can be accomplished: issues made by incision, if they be
large enough for the intended purpose, are apt to become inflam-
ed, and to be very troublesome before they come to suppuration;
but openings made by caustic are not in general liable to any of

3-10 ON THE PALSY OP

these inconveniences, at least not so frequently, nor in the same de-
gree: they arc neither so troublesome to make
or to maintain. I x" \ make the eschars about
this size and shape, on / \ each side the curve,
taking care to leave a j | sufficient portion of
skin between them: in I J a few days, when the
eschar begins to loosen \ / and separate, I cut out
all the middle, and ^^ put into each a large
kidney-bean. When the bottoms of the sores
are become clean by suppuration, I sprinkle, every third or fourth
day, a small quantity of finely powdered cantharides on them,
by which the sores are prevented from contracting, the discharge
increased, and possibly other benefit obtained. The issues I keep
open until the cure is complete: that is, until the patient recovers
perfectly the use of his legs, or even for some time longer; and I
should think that it would be more prudent to heal only one of
them first, keeping the other open for some time; that is, not only
until the patient can walk, but until he can walk firmly, briskly,
and without the assistance of a stick; until he can stand quite up-
right, and has recovered all the height, which the habit, or rather
the necessity of stooping, occasioned by the distemper, had made
liim lose.

I have said that the discharge by means of the issue, is all that
is requisite for a cure; which is true, as I have experimentally
proved by not using any other, in cases which have succeeded per-
fectly; but this fact being established, there is no reason why
every assistant means should not be applied at the same time, in
order to expedite: such as bark, ecld-bathing, frictions, &c.

That the patient becomes more upright as his legs become
stronger, is certain, and therefore appears taller, as well as straight-
er, in proportion as the whole spine strengthens; but whether the
curvature will always and totally disappear, I am not yet able to
say with certainty. In two late instances, both adults, it has;,
but the deformity which, in weak infants and children, is often
the consequence of the curvature, and of the state of the spine at
that place, must, in some degree, I fear, be expected to remain;
but of this I am not yet able to speak with absolute certainty-
There are a few other circumstances, of no great moment perhaps,

THE LOWER LIMBS. 341

but which will require more lime to ascertain than I thought
should be suffered to pass, before mankind were made acquainted
with the great means of relief, in so distressing, so melancholy,
and so dreadful a malady: for the reader will be pleased to re-
member what I told him at the beginning of this tract, which was,
that my motive for publishing this account sooner than might ap-
pear in general to be right, or indeed than I otherwise should have
done, was a desire that as little time as possible might be lost, in
conveying to the profession in particular, and to mankind in gene-
ral, the means of relief under an affliction, which, till these were
known, has not admitted of any; and this I was still more incited
to do, because the remedy is as harmless, and as void of hazard,
as it is efficacious.

In the preceding tract I have related the appearances which
the parts constituting the seat of the distemper make upon exami-
nation after death; or, to speak more properly, the different slates
of these parts in different persons, and at different periods of this
disease. These, though necessarily subject to considerable variety,
may, I think, be reduced to three general ones.

1. A small degree of an increase of size in the bodies of the
vertebrae, forming the curve, with an apparent laxity in their tex-
ture, and a relaxed state of the connecting ligaments, by which
they seem to have lost part of their power of holding the bones
together.

2. "A more considerable and more apparent enlargement of the
same parts of the vertebrae, whose spongy texture becomes more
visibly spread through their whole substance, and tending towards
a caries, with an apparently distempered state, both of the liga-
ments and of the intervening cartilages.

3. A truly carious state of the bodies of the bones; a dissolu-
tion or destruction of the cartilaginous substance between them;
and a lodgement of sanies on the surface of the membrane envelop-
ing the spinal marrow.

These are I think the most particularly different states or stages
of the disorder, and are such as, in my opinion, decisively mark
the true nature of it.

Between these, in different person?, and under different circum-

342 ON THE PALSY OF

stances, (here must be a considerable variety, but the material
difference will he only in degree.

From the whole, the few following practical inferences seem
fairly deducible:

1. That the disease does not originally consist in a displacement
of the vertebrae, made by violence, the bones and ligaments being
previously in a sound and uninjured state; but in such a morbid
alteration of the texture of both, as will, if not timely prevented,
produce curvature and caries, with all their consequences.

2. That the proper remedies for this disease cannot be applied
too soon.

3. That the restoration of the spine to its natural figure, depends
.much on the early administration of the help proposed.

4. That although the distemper may be so far cured, that the
patient may perfectly recover the use of his legs, yet such an
alteration may have taken place in the bodies of the vertebrae, as
to render it impossible for the spine to become straight again.

5. That when three or four, or more vertebra?, are concerned
in the curve, the trunk of the body will have so little support from
that part of the spine which is not distempered, that no degree of
deformity can be wondered at; nor can it be expected that such
deformity should be removed, whatever other benefit such patient
may receive.

6. That if from inattention, from length of time, or from any
other circumstances, it happens that the bodies of the vertebrae
become completely carious, and the intervening cartilages are
destroyed, no assistance is to be expected from the proposed
remedy.

To these I will take the liberty of adding, that it appears to me
well worth while, to try what a large and free discharge, made for
a length of time from the vicinity of the distempered part, might
be capable of doing in the very beginning of what are commonly
railed scrophulous joints; which, when arrived to a certain point,
bafHe all our art, and render a painful and hazardous operation
absolutely necessary.

Within these last six or eight months, several cases of curved
spine have been received into St. Bartholomew's hospital, where
they have been seen by great numbers of the profession. The

THE LOWER LIMBS. 343

novelty of the treatment, and the success which has hitherto con-
stantly attended it, has necessarily engaged the attention of many,
and occasioned some conversations on the subject. In some of
these it has been said, that as it appears to be undeniably a disease
of the bony texture of the bodies of the vertebra?, it may be appre-
hended, that the relief expected from the caustics may in some
cases fail, and in others may not prove permanent; and, that the
same kind of constitution remaining, a return of the malady may
not unreasonably be feared.

To this I can only answer, that although I have called this an
early publication, yet I have waited a sufficient length of time, and
have treated a sufficient number of subjects, to be clear in the truth
of what I have asserted, as far as such time, and such individuals
go. That the patients whom I have attended in the early part
of the distemper, of whatever age, have all got well; that is, have
all not only regained the use of their legs, but have become healthy,
and fit for any exercise or labour, as numbers can testify, who have
seen them daily. Most of them have become much straighter,
some quite straight, and all of them perfectly free from all kind of
inconvenience arising from the curve.

That in all the infants whom I have seen, the general health
of the patient has always been restored, in proportion to the resto-
ration of the use of the limbs.

That I must suppose all this to have been done by the discharge
from the caustics, because in many of them no other means of any
kind have been made use of.

That as far as my experience goes, I have not the least doubt,
that if the means proposed be made use of before the bones are
become really carious and rotten, they will always be successful.
When indeed a truly rotten state of the bones takes place, no good
is to be expected from this, or from any thing else: but it should
be observed, at the same time, that this never happens but when
the distemper is of very old date, and that, when this is the case,
the whole machine is so disordered, and the patient so truly and
so generally distempered, that there can be no reasonable expec-
tation of success from any thing.

To this I must take the liberty of adding, that what I have
affirmed, is what I have seen and proved, and that the objections

344 ON THE PALSY OF THE LOWER LIMBS.

are merely speculative and theoretical. However, supposing them
to be not quite unreasonable, the most useful inference to be drawn,
from them is, that the same remedy by which so great and so evi-
dent relief is obtained, ought lobe continued, while there may be
any fear of return of the mischief; and that every other means for
the restoration of health and strength should at the same time be
made use of; both which coincide absolutely with my own opinion
and advice.

FURTHER REMARKS

OJT THE

USELESS STATE OF THE LOWER LIMBS,

IX CONSEQUENCE OF

A CURVATURE OF THE SPINE,

"WITH

SOME OBSERVATIONS

ON THE

AUXILIARY ASSISTANCE OF MECHANISM, AND OTHER REMARKS.
BY THE EDITOR

VOL. II. XX

FURTHER REMARKS

PALSY OF THE LOWER LIMBS, &c.

It is now near three years since I first troubled the public with
my observations on the disease which makes the subject of the
following tract.

The apology which I then made, for what I was perfectly aware
might be thought a premature publication, was, that the distemper
to which it related was supposed to be incapable of receiving any
relief from art; and that they who were afflicted with it, were
therefore deserted, and left to linger out a most miserable exist-
ence; but that, from the benefit which I had seen to be derived
from a particular, and, at the same time, a perfectly safe method
of treating it, I thought that it demanded the immediate and seri-
ous regard of the profession.

Previous to the publication, I had considered the disease with
some attention, and had made some experiments on it, which, al-
though not many, were sufficient in number, and had been at-
tended with such a degree of success as to satisfy me, that it was a
subject in which mankind was much interested; but as I did not
think that any one man's experience, be it what it might, was
sufficient to determine a matter of so much importance, I wished
that ihe faculty at large might be made acquainted with what I
had seen and done, that they might be induced to make the same
experiment, and thereby either contradict or confirm what I had
said. If the former should be the result, my proposition would
soon mfet with the neglect which it would deserve; I could onh

346 ON THE PALSY OF

console myself with the rectitude of my intention, and be sorry for
my mistake: but if, on the contrary, the attempts of others should
prove as successful as mine, it appeared to me, that the chirurgic
art would make a great acquisition, as it would be thereby furnish-
ed with the means of relieving one of the most distressing mala-
dies to which human nature is liable; a malady which, when it
befalls an adult, makes him completely miserable, by depriving
him of all power of being useful to himself or others; a malady
which, when an infant becomes its victim, renders all the care and
tears, all the tenderness and anxiety of the fondest parent abso-
lutely unavailing, and a malady for which it was supposed there
was no remedy.

These were my reasons for hazarding my opinion so hastily;
the importance of the subject, and the perfect safety of the experi-
ment, were, as I thought, a sufficient excuse for so doing.

My wishes, and my expectations, have been most pleasingly
fulfilled. I have received such manifold and repeated testimony
of the success of the proposed method, from so large a number oi
the most eminent -practitioners, not only in this town and king-
dom, but in many other parts of Europe; that these, added to my
oWn experience, have completely satisfied me, and enabled me to
say, that in proper cases, and under proper treatment, I have no
doubt of its being universal.

In all the time which has passed since the first publication, I
have sought and embraced every opportunity of obtaining inform-
ation, both from the living and from the dead; and I have re-
quested and received the assistance of many friends, whose civili-
ties, and whose information, I take this opportunity of acknow-
ledging.

By these means I have been enabled to correct several errors,
and to make some additional observations, which I hope may not
only elucidate the original subject, but may serve other equally valu-
able purposes. Truths, built on observation and experience, seldom
stand single; ihey generally lead to others, and become the means
of more diffusive knowledge.

The disease of which I am to speak, is a disease of the spine,,
producing an alteration in its natural figure, and not unfrequentlv

/

THE LOWER LIMBS. ot9

attended with a partial, or a total loss of the power of using, or
even of moving, the lower limbs.

From this last circumstance, (the loss of the use of the limbs,)
it has in general been called a palsy, and treated as a paralytic af-
fection; to which it is in almost every respect perfectly unlike.

The occasion of the mistake is palpable; the patient is deprived of
the use of his legs, and has a deformed incurvation of the spine; the
incurvation is supposed to be caused by a dislocation of the vertebras;
the displaced bones are thought to make an unnatural pressure on
the spinal marrow; and a pressure on that being very likely to pro-
duce a paralysis of some kind, the loss of the use of the legs is in
this case determined to be such. The truth is, that there is no
dislocation, no unnatural pressure made on the spinal marrow;
nor are the limbs by any means paralytic, as will appear to who-
ever will examine the two complaints with any degree of atten-
tion.

In the true paralysis, from whatever cause, the muscles of tha
affected limb, are soft, flabby, unresisting,' and incapable of being
put into even a tonic slate: the limb itself may be placed in al-
most* any position or posture: if it be lifted up, and then let go, it
falls down, and it is not in the power of the patient to prevent, or
even to retard its fall: the joints are perfectly and easily moveable
in any direction: if the affection be of the lower limbs, neither
hips, knees, nor ankles, have any degree of rigidity or stiffness,
but permit the limb to be turned or twisted in almost any manner.

In the present case, the muscles are indeed extenuated, and
lessened in size; but they are rigid, and always at least in a tonic
state, by which the knees and ankles acquire a stiffness not very
easy to overcome. By means of this stiffness, mixed with a kind
of spasm, the legs of the patient are either constantly kept
stretched out straight, in which case considerable force is re-
quired to bend the knees, or they are by the action of the stronger
muscles drawn across each other in such manner as to require as
much to separate them: when the leg is in a straight position.
the extensor muscles act so powerfully as to require a consider-
able degree of force to bend the joints of the knees; and when
they have been bent, the legs are immediately and strongly drawn
«ip, with the heels toward the buttocks: by the rigidity of the

350 ON THE PALSY OF

ankle joints, joined to the spasmodic action of the gastrocnemii
muscles, the patient's toes are pointed downward in such manner
as to render it impossible for him to put his foot flat to the
ground; which makes one of the decisive characteristics of the
distemper.

These are strong marks of the distinction which ought to be
made between the two diseases; and fully sufficient to show the
impropriety of confounding them with each other.

The majority of those who labour under this disease are infants
or young children: adults are by no means exempt from it; but I
have never seen it at an age beyond forty.

When it attacks a child who is old enough to have walked pro-
perly, its awkward and imperfect manner of using its legs, is the
circumstance which first excites attention; and the incapacity of
using them at all, which very soon follows, fixes that attention,
and alarms the friends.

The account most frequently given is, that for some time pre-
vious to the incapacity, the child had been observed to be languid,
listless, and very soon tired; that he was unwilling to move much,
or briskly; that he had been observed frequently to trip and stum-
ble, although no impediment lay in his way; that when he moved
hastily or unguardedly, his legs would cross each other involunta-
rily, by which he was often and suddenly thrown down; that if he
endeavoured to stand still and upright, unsupported by another
person, his knees would totter and bend under him; that he could
not with any degree of precision or certainty steadily direct either
of his feet to any particular point, but that, in attempting so to
do, they would be suddenly and involuntarily brought across each
other; that soon after this, he complained of frequent pains and
twitchings in bis thighs, particularly when in bed, and of an un-
easy sensation at the pit of his stomach; that when he sat on a
chair, or a stool, his legs were almost always found across each
other, and drawn up under the seat; and that in a little time after
these particulars had been observed, he totally lost the power of
walking.

These are the general circumstances which are found, at least
in some degree, and that pretty uniformly, in most infants and

THE LOWER LIMBS. 351

children; but there are others which arc different in different sub-
jects.

If the incurvation be of the neck, and to a considerable degree,
by affecting several vertebrae, the child finds it inconvenient and
painful to support its own head, and is always desirous of laving
it on a table or pillow, or any thing to take off the weight. If the
affection be of the dorsal vertebras, the general marks of a dis-
tempered habit, such as loss of appetite, hard, dry cough, laborious
respiration, quick pulse, and disposition to hectic, appear pretty
early, and in such a manner as to demand attention; and as in
this state of the case there is always, from the connection between
the ribs, sternum, and spine, a great degree of crookedness of the
trunk, these complaints are by every body set to the account of
the deformity merely. In an adult, the attack and the progress
of the disease are much the same, but there are some few circum-
stances which may be learned from a patient of such age, which
either do not make an impression on a child, or do not happen
to it.

An adult, in a case where no violence hath been committed, or
received, will tell you, that his first intimation was a sense of
weakness in his back bone, accompanied with what he will call a
heavy, dull kind of pain, atteuded with such a lassitude as render-
ed a small degree of exercise fatiguing; that this was soon followed
by an unusual sense of coldness in his thighs, not accountable for
from the weather, and a palpable diminution of their sensibility:
that, in a little time more, his limbs were frequently convulsed by
involuntary twitchings, particularly troublesome in the night; that
soon after this, he not only became incapable of walking, but that
his power either of retaining or discharging his urine and fasces
was considerably impaired, and his penis became incapable of
erection.

The adult also finds all the offices of his digestive and respiratory
organs much affected, and complains constantly of pain and tight-
ness at his stomach.

In infants, the curve is seldom noticed till it has got to such
size and state, as to demand attention from the deformity: previ-
ous to this, all the marks of distemper which appear in the child,

ON THE PALSY OF

pass for the effects of general weakness, and are treated as such;
differently by different people, and under different circumstances,
but never with any permanent good effect; some of the adventi-
tious symptoms, if 1 may so call them, are, in some degree, reliev-
ed; but the principal remain in full force, or, what is much more
frequent, go on increasing.

In an adult it passes for rheumatism, or gravel, or a strain;
and the defect in the limbs is the first thing that occasions an in-
quiry into the slate of the back bone.

When a curvature is perceived in an infant, it is always sup-
posed to have received a hurt by a blow or Tall, and an adult has
always recourse to some exertion in pulling, drawing, lifting, or
carrying, by which the spine is thought to have been deranged, or
injured; but which supposition is seldom, if ever, true in either
case.

The true cause of the disease is a morbid state of the srine, and
of some of the parts connected with it; which distempered state of
parts will, upon careful inquiry, be always found to have preceded
the deformity some length of time: in infants this is the sole cause,
and external violence has nothing to do with it. In the adult, I
will not assert that external mischief is always and totally out of
the question, but I will venture to affirm what is equal, as far as
regards the true nature of the case, which R, that although acci-
dent and violence may in some few instances be allowed to have
contributed to its more immediate appearance, yet the part in
which it shows itself, must have been previously in a morbid state,
and thereby predisposed for the production of it. I do not by this
mean to say that a violent exertion cannot injure the spine, nor
produce a paralytic complaint; that would be to say more than I
know: but I will venture to assert, that no degree of violence
whatever is capable of producing such an appearance as I am now
speaking of, unless the bodies of the vertebrae were by previous
distemper disposed to give way; and that no supposable disloca-
tion, caused by mere violence done to the bones of the back, which
hones were before the receipt of the injury in a sound state, can
possibly be attended with the peculiar symptoms of a curved spine.
In which distinction, according to my judgment, consists the very
essence of the disease. Violence may easily be supposed to bring

THE LOWER LIMBS. 353

the two vertebrae nearer to each other than they ought to be, and
by crushing an intermediate one to produce a curvature; but then
the body of the vertebra? so crushed, must have been in a distem-
pered st;;te previous to such violence. Great violence may also
suddenly and immediately displace a perfectly sound vertebra
from its proper and natural situation, with regard to those annex-
ed to it; but the necessary consequences of these two kinds of in-
jury must be so very different, that they never can be confounded
together, or mistaken for each other, even by the most inattentive
observer.

The true curvature is invariably uniform in being from within
outwards; but it varies in situation, in extent, and in degree; it
affects the neck, the back, or the loins; it comprehends one verte-
bra only, or two, or more; and as few or more are affected, or,
as these are more or less morbid, and consequently give way more
or less, the curve must be different: but whatever variety these
circumstances may admit, the lower limbs alone, b in general, feel
the effect. Some are, very soon after the curvature, rendered totally
and absolutely incapable, not only of walking, but of using their
legs in any manner; others can make shift to move about with the
help of crutches, or by grasping their thighs, just above the knees,
with both hands; some can sit in an armed chair without much
trouble or fatigue, others cannot sit up with any help; some retain
such a degree of power of using their legs, as to be able to shift
their posture when in bed; others have no such power, and are
obliged to be moved upon all occasions.

Weak and delicate children are the most frequent subjects of
this distemper; and when, in these, it seizes on the dorsal verte-
brae, great delbjmity of the trunk, both before and behind, is the
almost inevitable and necessary consequence: this will be differ-

b Since I began to put these papers together, I have seen two cases, in
one of which the arms only were aff< cted; ,n the o'.her both legs and arms.

Mr. K. Ford, of Golden square, has favoured me with the examination and
case of a lad, who lost the use of both le^s, and both arms, from a curvature,
which Mr. Ford cured by means of the caustics. Mr. Parke, of Liverpool,
has also obliged me with an ace Hint of two persons, both under his care,
both with useless arms and legs, and both cured by the same means.
VOL. II. Y V

354 ON THE PALSY OF

ent in different persons; but let the difference in this be what it
may, it is an adjunct circumstance; and upon due inquiry it will
always be found, that the curvature from within outward preceded
the other deformity, and was, at one time, the only one to be
seen.

Before the alteration of figure in the back bone has been dis-
covered, all the attention is paid to the limbs, in which the whole
disorder is supposed to reside, and all the applications for relief
are made to them; frictions, liniments, embrocations, blisters, &c.
in which is generally added cold bathing and electricity. When
the curvature has been noticed, recourse is immediately had to
back boards, collars, steel boddice, swings, screw chairs, and
other pieces of machinery, but all to no purpose; the patient be-
comes daily more and more helpless and unhealthy, languishes
for more or less time, and at last dies either in an emaciated state
from an hectic, or by a drain from an abscess formed within the
body.

That this is the case frequent and melancholy experience
evinces; but why it is so, is perhaps not generally so well under-
stood or attended to as it ought to be.

The primary and sole cause of all the mischief, is a distemper-
ed state of the parts composing, or in immediate connexion with, the
spine, tending to, and most frequently ending in, a cariesof the body,
or bodies, of one or more of the verlebrac: from this proceed all the
ills, whether general or local, apparent or concealed; this causes
the ill health of the patient, and, in time, the curvature. The
helpless state of the limbs is only one consequence of several, pro-
ceeding from the same cause; but though this effect is a very fre-
quent one, and always affects the limbs in nearly the same man-
ner, yet the disease not having its origin in them, no application
made to them only can ever be of any possible use.

The same failure of success attends the use of the different
pieces of machinery, and for reasons which are equally ob-
vious.

They are all, from the most simple to the most complex, but
particularly the swing and the screw, calculated to obviate and
remove what does not exist. They are founded upon the supposi-

THE LOWER LIMBS. 355

tion of an actual dislocation, which never is the case, and therefore
they always have been, and ever must be, unsuccessful.

To understand this in the clearest and most convincing man-
ner, we need only reflect on the nature of the disease, its seat, and
the state in which the parts concerned must necessarily be.

The bones are either already carious, or tending to become so;
the parts connected with them are diseased, and not infrequently
ulcerated; there is no displacement of the vertebrae with regard to
each other; and the spine bends forward only because the rotten
bone or bones, intervening between the sound ones, give way,
being unable in such state to bear the weight of the parts above.
The most superficial reflection on this must point out to every one,
why attempts of this kind can do no good; and a little more at-
tention to the subject will show why they may be productive of
real and great mischief. The bones are supposed to be sound,
but displaced: these machines are designed to bring them back to
their former situation, and thereby to restore to the spine its pro-
per rectitude. If therefore they have any power, that power must
be exercised on the parts in connexion with the curve; which
parts, when the disease is at all advanced, are incapable of bear-
ing such a degree of violence without being much hurl thereby:
this, if it were merely theoretical, being a conclusion drawn from
the obvious and demonstrable state of the distempered parts, could
not be deemed unreasonable; but, unfortunately for the afflicted,
it is confirmed by practice. They who have had patience and
fortitude to bear the use of them to such a degree as to affect the
parts concerned, have always found increase of pain and fever,
and an exasperation of all their bad symptoms; and I have
known more than one instance in which the attempt has proved
fatal.

The use of some or other of these pieces of machinery is so ge-
neral, and the vulgar prejudice in their favour so great, that not-
withstanding I have been long convinced of their perfect inutility,
yet if I had no other objection to them, I would not attempt to
rob the afflicted of what they seem to derive such comfortable ex-
pectation from; but as I am satisfied of their mischievous effects,
not only in the case of the present subject, but in many others, I

356 ON THE PALSY OF

cannot help bearing my testimony against the indiscriminate and
very improper use which is daily made of them.

They are used with design to prevent growing children from be-
coming crooked or misshapen; and this they are supposed to do
by supporting the back bone, and by forcing the shoulders unnatu-
rally backward: the former they cannot do; and in all cases where
the spine is weak, and thereby inclined to deviate from a right
figure, the latter action of these instruments must contribute to,
rather than prevent such deviation; as will appear to whoever will
with any attention examine the matter: if, instead of adding to the
embarrassments of children's dress by such iron restraints, parents
•would throw oft* all of every kind, and thereby give nature an op-
portunity of exerting her own powers; and if, in all cases of mani-
fest debility, recourse was had to friction, bark, and cold bathing,
with a due attention to air, diet, exercise, and rest, the children
of the opulent would, perhaps, stand a chance of being as stout,
as straight, and as well shapen as those of the laborious poor.

When a child appears to be what the common people call natu-
rally weakiy, whatever complaints it may have are supposed to be
caused by its weak state, and it is generally believed that time and
common care will remove them; but when a curvature has made its
appearance, all these marks of ill health, such as laborious respi-
ration, bard cough, quick pulse, hectical heat and flushing, pain
and tightness of the stomach, &c. are more attentively regarded,
and set to the account of the deformity consequent to the curve,
more especially if the curvature be of the dorsal vertebrae; in which
case the deformity is always greatest: but whoever will carefully
attend to all the circumstances of this disorder, will be convinced,
that most, if not all the complaints of children, labouring under
this infirmity, precede the curvature, and that a morbid state of
the spine, and of the parts connected with it, is the original and
primary cause of both.

c When I published the first edition of this tract, I was not so aware of this
truth, as a more enlarged experience in, and a more careful attention to, the
disorder since has made me.

I am very glad to embrace this opportunity of acknowledging, and of cor-
recting the mistake, and the more so, as I am convinced that an inference of
the greatest importance may be drawn from it. I am satisfied that this malady

THE LOWER LIMBS. 357

I have in the former edition informed the reader, that my par-
ticular attention to this disease was first excited by an instance of
its being cured by a seemingly accidental abscess; thai this first
gave me reason to suspect, that we had mistaken an effect lor
a cause; and that, upon mature deliberation upon the matter, I
was still more inclined to think so, for the following reasons:

1. " That I did not remember ever to have seen this useless
" state of the limbs from a mere malformation of the spine, how-
" ever crooked such malformation might have made it.

2. " That none of those deviations from right shape, which
" growing girls are so liable to, however great the deformity might
" be, was ever attended with this effect.

3. " That the kind of deformity, which was attended with this
" affection of the limbs, although it was different as to its degree
" and its extent in different people, yet it was uniform in one cir-
" cumstance, which was, that the curvature always was from
" within outwards.

4. " That since I had been particularly attentive to the disorder,
" I thought that I had observed, that neither the extent nor degree
" of the curve, had in general produced any material difference in
" the symptoms, but that the smallest was, when perfectly formed,
« attended with the same consequences as the largest.

5. " That although it had sometimes happened, that a blow, or
" a strain, had preceded the appearance of the curve, vet it much
" more frequently happened, that no such cause was assignable.

6. " That I had observed exactly the same symptoms in infants,
" and in young children, who had neither exerted themselves, nor
" were supposed to have received any injury from others; and that
« the case was still the same in those adults, who had no such
" cause to look to.

7. " That although it might be expected that a dislocation of
" any of the vertebrae would be attended with symptoms of the
" paralytic kind, yet they would be very unlike to those which
" affected the limbs in the present case."

may, in many instances, by early and proper attention, be prevented from
producing its otherwise inevitable consequences, temporary lameness, and
permanent deformity.

358 ON THE PALSY OF

The suspicions which these circumstances had excited in my
mind, were confirmed' 1 by what I had a few opportunities of observ-
ing in the dead bodies of some, who had died afflicted with this dis-
order, and altogether satisfied mc, that there r.iust be something pre-
disposing in the parts concerned; and that when we attribute the
useless state of the limbs merely to the curvature, we mistake, as I
have just said, an effect for a cause.

At the same lime I gave an account of a conversation which
passed between me and the late Dr. Cameron, of Worcester, who
told me, that having remarked in Hippocrates an account of a
paralysis of the lower limbs cured by an abscess in the back, he
had, in a case of useless limbs, attended with a curvature of the
spine, endeavoured to imitate this act of nature, by exciting a
purulent discharge, and that it had proved very beneficial; which
was confirmed to me by Mr. Jeffrys, of Worcester, who had made
the same experiment with the same success. e

From the time of my receiving this first information to the present,
I have sought every opportunity of making the experiment. St.
Bartholomew's hospital has seldom been without cases of this kind,
and it is with infinite pleasure and satisfaction, that I find myself
enabled to say, that in all cases where the complaint has been so
circumstanced as to admit of even probable expectation, the attempt
has been successful.

If the cure of this most dreadful distemper had depended upon

d In the first edition, I had described the bones on which the disease had
seized, as being enlarged and spread : upon repeated inquiry and examination,
I am convinced that they are not.

The bodies of the vertebrae concerned are often affected, while the liga-
ments bear but little mark of distemper ; but whether the ligaments be
affected or not, the bodies of the vertebrae are always diseased, which disease
does not so properly enlarge as erode: the state also of the intervertebral
cartilages, I find to be subject to great 'variety, they being sometimes to-
tally destroyed, while the caries is small in degree, sometimes apparently but
little injured, where the caries has done considerable mischief, and sometimes
totally destroyed and annihilated.

e In this place- of the first edition, I have a short account of the first two or
three cases which occured to me : in this I omit them as needless.

The number of experiments which have been made by many of the most
eminent practitioners, at home and abroad, have sufficiently established the
fact., and render the relation of particular cases unnecessary.

THE LOWER LIMES.

359

an application to the constitution in general, it might have re-
quired a variety of medicines, the administration of which must
have demanded judgment in adapting them to particular persons
and constitutions; and it must also, in the nature of things, have
happened that many individuals could not have been benefited at
all. But fortunately for the afflicted, the means of relief are sim-
ple, uniform, and safely applicable to every individual, under al-
most every possible circumstance, not attended by the smallest
degree of hazard, and capable of being executed by any body who
has the least portion of chirurgic knowledge: it consists merely in
procuring a large discharge of matter from underneath the mem-
brana adiposa, on each side of the distempered bones forming the
curvature, and in maintaining such discharge until the patient shall
have recovered his health and limbs. They who are little con-
versant with matters of this sort, will suppose the means very in-
adequate to the proposed end; but they who have been experimen-
tally acquainted with the very wonderful effects of purulent drains,
made from the immediate neighbourhood of diseases, will not be
so much surprised at this particular one; and will immediately see
how such kind of discharge, made and continued from the dis-
tempered part, checks the further progress of the caries, gives na-
ture an opportunity of exerting her own powers, of throwing off the
diseased parts, and of producing by incarnation an union of the
bones, (now rendered sound,) and thereby establishing a cure.

However, be all this as it may, the fact is undoubted, and
the number of witnesses, as well as patients, producible in con-
firmation of it, is so considerable, that it is needless to say any
thing more on that head.

It is a matter of little importance towards the cure, by what
means the discharge be procured, provided it be large, that it come
from a sufficient depth, and that it be continued for a sufficient
length of time. 1

I have tried the different means of setons, issues by incision,
and issues by caustic, and have found the last in general prefer-

f When I say this, I mean to signify that it is absolutely without limitation,
and must depend on their beneficial effect.

360 ON THE PALSY OF

able, being least painful, most cleanly, most easily manageable,
and capable of being longest continued.

The caustics should be applied on each side of the curvature,
in such a manner as to leave the portion of skin covering the spi-
nal processes of the protruding bones, intire and unhurt; and so
large, that the sores, upon the separations of the eschars, may
easily hold each three or four peas in the case of the smallest cur-
vature; but in large curves, at least as many more.

These issues should not only be kept open, but the discharge
from them should be maintained by means of orange peas, can-
tharides in fine powder, aerugo aeris, or any such application as
may best serve the intended purpose, which should be that of a
large and long continued drain.

Whatever length of time it may take to obtain a complete cure,
by restoring the health as well as the limbs, the issues must be
continued at least as long; and, in my opinion, a considerable
time longer, especially in the persons of infants and growing
children; the necessity of which will appear more strongly, when
it shall be considered that infants and young children of strumous
habits, are the subjects who are most liable to this distemper, and
that in all the time previous to menstruation in one sex, and pu-
berty in the other, they are in general more served by artificial
drains than any other persons whatever.

This, and this only, does or can alleviate the misery attending
this distemper, and in proper time effect a cure.

By means of these discharges, the eroding caries is first check-
ed, and then stopped; in consequence of which an incarnation
takes place, and the cartilages between the bodies of the vertebrae
having been previously destroyed, the bones become united with
each other, and form a kind of anchylosis.

The time necessary for the accomplishment of this, must, in the
nature of things, be considerable in all cases, but very different,
according to different circumstances.

No degree of benefit or relief, nor any the smallest tendency
towards a cure, is to be expected until the caries be stopped, and
the rotten bones have begun to incarn: the larger the quantity of
bones concerned, and the greater degree of waste and havock
committed by the caries, the greater must be the length of time

THE LOWER LIMBS. 361

required for the correction of it, and for restoring to a sound state
so large a quantity of distempered parts — and vice versa.g

In the progress toward a cure, the same gradation or succes-
sion of circumstances may be observed^ as was found to attend the
formation of the disease; with this difference, that they which at-
tend the latter, are much more rapid than those which accompany
the former.

After the discharge has been made some lime (very uncertain.
what), the patient is found to be better in all general respects;
and if of age to distinguish, will acknowledge that he feels him-
self to be in better health; he begins to recover his appetite, gets
refreshing sleep, and has a more quiet and less hectical kind of
pulse; but the relief which he feels above all others, is from hav-
ing got rid of that distressing sensation of tightness about the sto-
mach: in a little time more, a degree of warmth and a sensibility
is felt in the thighs, which they had been strangers to fbr some
time; and generally, much about the same time, the power of re-
taining and discharging the urine and faeces begins to be in some
degree everted.

The first return of the power of motion in the limbs is rather
disagreeable, the motions being involuntary, and of the spasmodic
kind, principally in the night; and generally attended with a sense
of pain in all the muscles concerned.

At this point of amendment, if it may be so called, it is no un-
common thing, especially in bad cases, for the patient to stand
some time without making any further progress: this in adults oc-
casions impatience, and in parents despair: but inlhe milder kind
of case, the power of voluntary motion generally soon follows the
involuntary.

The knees and ankles by degrees lose their stiffness, and the re-
laxation of the latter enables the patient to set his feet flat upon the
ground, the certain mark that the power of walking will soon fol-
low: but those joints, having lost their rigidity, become exceed-

e Nothing' can be more uncertain than the time required for the cure of
this distemper. I have seen it perfected in two or three months, and I have
known it require two years; two-thirds of which time passed before there
was any visible amendment.

VOL. II. 7. Z

262 ON THE PALSY OP

ingly weak, and are not for some time capable of serving the pur-
pose of progression.

The first voluntary motions are weak, not constantly perform-
able, nor even every day,' and liable to great variation, from a
number of accidental circumstances, both external and internal.

The first attempts to walk are feeble, irregular, and unsteady,
and bear every mark of nervous and muscular debility; the patient
stands in need of much help; and his steps, with the best support,
will be, as 1 have just said, irregular and unsteady: but when they
have arrived at this, I have never seen an instance in which they
did not soon attain the full power of walking.

When the patient can just walk, either with crutches, or be-
tween two supporters, he generally finds much trouble and incon-
venience, in not being able to resist, or to regulate, the more power-
ful action of the stronger muscles of the thigh over the weaker,
by which his legs are frequently brought involuntarily across each
other, and he is suddenly thrown down.

Adults find assistance in crutches, by laying hold of chairs,
tables, &c; but the best and safest assistance for a child, is what
is called a go-cart, of such height as to reach under the arms, and
so made as to enclose the whole body: this takes all inconvenient
weight off from the legs, and at the same time enables the child
to move them as much as it may please.

Time and patience are very requisite: but they do in this case,
as in many others, accomplish our wishes at last.

The deformity, remaining after recovery, is subject to great un-
certainty, and considerable variety, as it depends on the degree
of caries, and the number of bones affected; in general, it may
be said, that where one vertebra only is affected, and the patient
young, the curve will in length of time almost totally disappear:
but where two or three are affected, this cannot be expected.
The thing aimed at is the consolidation and union of the bones,
which had been carious, and are now become sound: this is the
sine qua non of the cure, and this must in such cases render the
curvature, and consequently the deformity, permanent: the issues
will restore the use of the limbs, but not the lost figure of the
spine.

THE LOWER LIMBS. 363

Since this method of treating the distemper has been made
known, the disease itself has been more adverted to, and applica-
tions for relief have been more frequent than they were while it
was regarded as incurable. The number received into St. Bar-
tholomew's hospital has been considerable, and, as it may be
supposed, some in a state to admit of cure, others not. While
the thing was new, and before a number of cures sufficient to
establish the fact had been wrought, it was doubted by most and
positively denied by some: but since a variety of successes has
put the matter beyond all doubt, with regard to the restoration of
the use of the limbs, it has been said, that as the disease is mani-
festly a disease of the bones, it is to be apprehended, that the ex-
pectation of relief may in some cases fail, and that in others it
may not prove permanent; that the same kind of constitution re-
maining, a return of the malady may be feared; and, in short,
that a much greater degree of uncertainty may occur, than might
be expected from the account which I have given.

To the first I answer, that in cases where the caries is very ex-
tensive, and the constitution has been thereby so injured as to
produce a degree of mischief tending to the destruction of the pa-
tient, no good is to be expected; the disease has been too long ne-
glected, and is become thereby an overmatch for the remedy.
But how does this differ from what may be said, with the same
truth, of every disease, and of every remedy? To the second,
third, and fourth remark, all I can say is, that in the space of
three years, during which I have had many opportunities of mak-
ing the experiment, I have met with but one single instance in
which it has failed, where, from the state of the disease, and of
the patient, there was any reasonable foundation for hopes; that
all those who have submitted to keep the issues open long enough,
have been so restored to health, and to the free use of their limbs,
as to be perfectly capable, not only of exercise, but of hard la-
bour; and that I have never yet, among those so treated, met with
one on whom the disease has returned.

On the other hand, the nature of the original distemper in the
habit, its effects, both local and general, the gradual, slow manner
in which alone a cure is obtainable, and the particular circum-

364 ON THE PALSY OF

stance on which such cure entirely depends, I mean the removal
of the caries, and the union of the bones with each other, all very
strongly point out the propriety of continuing that discharge for a
sufficient length of time, from which, and from which only, such
benefit has been derived.

At the beginning of the preceding tract I have said, that when
I first began to consider the distemper with that degree of at-
tention which it seemed to deserve, I was inclined to suspect that
we had hitherto regarded it too superficially; that we had been
satisfied with observing its external appearance merely, without
inquiring into its real nature; that we had thereby been led to
mistake an effect for a cause; and that there must certainly be,
either in the constitution of the patient, or in the state of the parts
concerned, something which tended to produce this very dreadful
malady.

I am satisfied I was right in my conjecture, and am convinced,
from every circumstance, general and particular, in the living, and
from every appearance in the dead, that the complaint arises from
what is commonly called a strumous or scrophulous indisposition,
affecting the parts composing the spine, or those in its immediate
vicinity.

This morbid affection shows itself in a variety of forms; but, al-
though its appearances be various, yet they are always 'such as
determine the true nature of the distemper.

Sometimes it appears in a thickened state of the ligaments, con-
necting the vertebrae together, without any apparent affection of
the bones.

Sometimes in the form of a distempered state of the interver-
tebral substances, called cartilages.

Sometimes in that of diseased glands, either in a merely indu-
rated and enlarged state, or, what is more frequent, in that of a
partial suppuration.

Sometimes it is found in the form of bags or cysts, containing a
quantity of stuff of a very unequal consistence, partly purulent,
partly anion., and partly a curd-like kind of substance; and not
Unfreqiienlly entirely out of the last.

THE LOWER LIMES. 365

Sometimes under these bags, or cysts, even while they remain
whole, the subjacent bones are found to be distempered; that is,
deprived of periosteum, and lending to become carious.

Sometimes these collections erode the containing membranes,
and make their way downward by the side of the psoas muscle,
toward the groin, or by the side of the pelvis behind the great tro-
chanter, or in some cases to the outside of the upper part of the
thigh.

Sometimes each of the distempered states of these parts is ac-
companied by a greater or less degree of deformity and crooked-
ness of the spine, without any apparent disease of the bones com-
posing it: sometimes the deformity is attended with an erosion, or
caries of the body or bones of some of the vertebrae; and some-
times the same bones are found to be carious, without any crook-
edness or alteration of figure.

These different affections of the spine, and of the parts in its
immediate neighbourhood, are productive of many disorders, ge-
neral and local, affecting the whole frame and habit of the patient,
as weli as particular parts; and, among the rest, of that curvature
which is the subject of this inquiry; and it may not be amiss to re-
mark, that strumous tubercles in the lungs, and a distempered
state of some of the abdominal viscera, often make a part of them.

From an attentive examination of these morbid appearances,
and of their effects in different subjects, and under different cir-
cumstances, the following observations, tending not only to illus-
trate and explain the true nature of the disease in question, but
also to throw light on others of equal importance, may, I think,
be made.

1 . That the disease which produces these effects on the spine,
and the parts in its vicinity, is what is in general called the scro-
phula; that is, that same kind of indisposition as occasions the
thick upper lip, the tedious, obstinate ophthalmy, the indurated
glands under the chin and in the neck, the obstructed mesentery,
the hard, dry cough, the glairy swellings of the wrist and ankles,
the thickened ligaments of the joints, the enlargement and caries
of the bones, &c. &c. &c.

2. That this disease^ by falling on the spine, and the parts con-

366 ON THE PALSY OF

nected with it, is the cause of a great variety of complaints, both
general and local.

3. That when these complaints are not attended with an altera-
tion of the figure of the back bone, neither the real seat, nor true
nature of such distemper are pointed out by the general symptoms;
and consequently, that they frequently are unknown, at least while
the patient lives.

4. That when by means of this distemper an alteration is pro-
duced in the figure of the back bone, that alteration is different in
different subjects, and according to different circumstances.

5. That when the ligaments and cartilages of the spine become
the seat of the disorder, without any affection of the vertebra), it
sometimes happens that the whole spine, from the lowest verte-
bras of the neck downwards, gives way laterally, forming some-
times one great curve to one side, and sometimes a more irregular
figure, producing general crookedness and deformity of the whole
trunk of the body, attended with many marks of ill health.

6. That these complaints, which are by almost every body sup-
posed to be the effect of the deformity merely, are really occasion-
ed by that distempered state of the parts within the thorax, which
is at the same time the cause both of the deformity and of the
want of health.

7. That the attack is sometimes on the bodies of some of the ver-
tebras; and that when this is the case, ulceration or erosion of the
bone is the consequence, and not enlargement.

8. That when this erosion or caries seizes the body or bodies
of one or more of the vertebras, it sometimes happens that the
particular kind of curvature which makes the subject of these
sheets is the consequence.

9. That this curvature, which is always from within outward,
is caused by the erosion or destruction of part of the body or bo-
dies of one or more of the vertebras; by which means that imme-
diately above the distemper, and that immediately below it, are
brought nearer to each ether than they should be, the body of the
patient bends forward, the spine is curved from within outward,
and the tuberosity appears behind, occasioned by the protrusion of

THE LOWER LIMBS. 367

the spinal processes of the distempered vertebra?. See plate 1.2,
and 3.

10. That according to the degree of carious erosion, and ac-
cording to the number of vertebrae affected, the curve must be
less or greater.

1 1 . That when the attack is made upon the dorsal vertebra?,
the sternum and ribs, for want of proper support, necessarily give
wav, and other deformity, additional to the curve, is thereby pro-
duced.

• 12. That this kind of caries is always confined to the bodies of
the vertebrae, seldom or never affecting the articular processes. 11

13. That without this erosive destruction of the bodies of the
vertebrae, there can be no curvature of (he kind which I am speak-
ing of; or, in other words, that erosion is the sine qua non of this
disease; that although there can be no true curve without caries,
yet there is, and that not infrequently, caries without curve. See
plate 5.

14. That the caries with curvature and useless limbs, is most
frequently of the cervical or dorsal vertebrae; the caries without
curve, of the lumbal, though this is by no means constant or ne-
cessary.

15. That in the case of carious spine, without curvature, it
most frequently happens, that internal abscesses and collections of
matter are formed, which matter makes its way outward, and ap-
pears in the hip, groin, or thigh; or being detained within the
body, destroys the patient; the real and immediate cause of whose
death is seldom known, or even rightly guessed at, unless the
dead body be examined.

16. That what are commonly .called lumbal and psoas ab-
scesses, are not infrequently produced in this manner, and therefore
when we use these terms, we should be understood to mean only
a description of the course which such matter has pursued in its
way outward, or the place where it makes its appearance exter-
nally, the terms really meaning nothing more, nor conveying any

l> I have seen two cases in which the bodies of the vertebrae were totally
separated from all connexion with the other parts, leaving the membrane,
which included the spinal marrow, perfectly bare. See plate 4.

368 ON THE PALSY OF

precise idea of the nature, scat, or origin of a distemper, subject to
great variety, and from which variety its very different symptoms
and events, in different subjects, can alone be accounted for.

17. That contrary to the general opinion, a caries of the spine
is more frequently a cause than an effect of these abscesses.

18. That the true curvature of the spine, from within outward,
of which the paralytic, or useless state of the lower limbs, is a
too frequent consequence, is itself but one effect of a distempered
spine; such case being always attended with a number of com-
plaints which arise from the same cause; the generally received
opinion, therefore, that all the attending symptoms are derived
from the curvature, considered abstractedly, is by no means found-
ed in truth, and may be productive of very erroneous conduct.

19. That in the case of true curvature, attended with useless
limbs, there never is a dislocation, properly to be so called, but
that the alteration in the figure of the back bone is caused solely
by the erosion, and destruction of a part of one or more of the cor-
pora vertebrarum; and, that as there can be no true curvature with-
out caries, it must be demonstrably clear, that there must have
been a distempered state of parts previous to such erosion; from
all which it follows, that this distemper, call it by what name you
please, ought to be regarded as the original cause of the whole;
that is, of the caries, of the curvature, and all the attendant mis-
chiefs, be they what they may, general or particular; a considera-
tion, as it appears to me, of infinite importance to all such infants
and young children, as show, either from their general complaints,
or from their shape, a tendency to this kind of evil; and whose
parents and friends generally content themselves with a swing, or
piece of iron machinery, and look no further.

20. That whoever will consider the real state of the parts
when a caries has taken. place, and the parts surrounding it are
in a state of ulceration, must see why none of the attempts, by
means of swings, screws, &c. can possibly do any good, but on
the contrary, if they act so as to produce any effect at all, it must
be a bad one.

21. That the discharge, by means of the issues, produces in
due time (more or less under different circumstances) a cessa-
tion of the erosion of the bones, that this is followed by an incar-

THE LOWER LIMBS. 369

nation, by means of which the bodies of the vertebrae which had
bet]] the seat of ihe disease, coalesce, and unite with each other,
forming a kind of anchylosis.

22. That the different degrees and extent of the caries, in dif-
ferent subjects, must render all attempts to cure uncertain, both
as to the time required, and as to the ultimate event: the least and
smallest degree will (every thing else being equal) be soonest
relieved and cured: the larger and more extensive will require
more time; and where the rottenness is to a great degree, and all
the surrounding parts in a state of distempered ulceration, it must
foil all attempts, and destroy the patient.

23. That when two or more vertebras are affected, forming a
large curve, however perfect the success may be with regard to
the restoration of health and limbs, yet the curvature will and must
remain, in consequence of the union of the bones with each other.

21. That the useless state of the limbs is by no means a conse-
quence of the altered figure of the spine, or of the disposition of
the bones with regard to each other, but merely of the caries: of
this truth there needs no other proof, than what may be drawn
from the cure of a large and extensive curvature, in which three or
more vertebras were concerned: in this the deformity always re-
mains unaltered and unalterable, notwithstanding the patient re-
covers both health and limbs.

Upon the whole, after due consideration of what has been said
concerning the nature of the complaint, its producing cause, and
the method by which it is capable of being cured, I would ask,
whether the diseased state of the spine, and of the parts connected
with it, (which, if not prevented, must produce some of its very
dreadful effects,) may not, by a timely use of proper means, be
prevented?

A morbid slate of parts previous to deformity, caries, or curve,
must be allowed: every complaint of the living, and every appear-
ance in the dead, prove it beyond contradiction or doubt. All
the general complaints of persons afflicted with this disorder, will
always, upon careful inquiry, be found to have preceded any degree
of deformity, to have increased as the curve became apparent, and
to have decreased as the means used for relief took place: the pain
and tightness about the stomach, the indigestion, the want of appe-

vol. n 3 a

610 ON THE PALSy OP

tite, the disturbed sleep, &c. &c. gradually disappear, and the
marks of returning health become observable, before the limbs re-
cover the smallest degree of their power of moving.

On the other hand, it is as true, that when, from extent, or degree,
or inveteracy of the caries, the issues are found to be unequal to
the wished for effect, the general complaints receive no amend-
ment, but increase until the patient sinks under them.

If all this be true, which, that it is, the manifold and repeated
experience of many, as well as myself, can amply testify; and if
it be found that the issues are capable of effecting a perfect cure,
even after a caries has taken place, and that to a considerable
degree, which is also true to demonstration, is it not reasonable to
conclude, that the same means, made use of in due time, might
prove preventive?

If this was a matter of mere speculation or opinion, I would be
very cautious how I spake on the subject: but it is really a matter
of experiment; and as far as I have had it in my power to put it to
that test, it has succeeded, by the restoration of lost health, and the
prevention of a deformity which was advancing rapidly.

It may, perhaps, be said, that if no such means had been used,
the same space of time might have produced the same effect: to
this it is impossible to make an answer: I shall, therefore, content
myself with having given my opinion, with the circumstances and
reasons on which it is founded.

I should be sorry to be misunderstood on this point, or to have
it thought that I meant to say, that every weak or rickety child was
necessarily liable to a curved spine; or that issues were to be deemed
an infallible remedy for the ills arising from a strumous habit: far
be it from me to say either: what I would wish to be understood
to mean is, that such kind of habit appears to me to be most apt to
produce some of the mischiefs mentioned in this tract; that, as a
purulent discharge, derived from, the neighbourhood of the spine,
is found, from repeated experience, to be a successful remedy, even
after the disease is confirmed by a caries, it seems to me to bid fairer
than any thing else, if used in time, to become a preventive; and that,
as some other kinds of deformity are found to follow attacks of the
same kind of constitutional disorder seizing on these parts, and
which, though not causing precisely the .same effect, areneverthe-

THE LOWER LIMBS. 371

less attended with the same general symptoms, I cannot help think-
ing, that it may be well worth while to try whether benefit be
not attainable by the same means, in the one case as in the other;
and if the old maxim, " anceps remedium quam nullum" be admissi-
ble, surely an experiment, which is in its nature perfectly inca-
pable of harm, is worth making.

■SVZ ON THE PALSY OF

* :)( * Since Mr. Pott made his first observations on tins disease;
it has much engaged the attention of the profession, and from re-
peated examinations it has been proved to be caused by the giving
way of (he bodies of some of the vertebra, owing to a loss of sub-
stance produced by caries: in many cases the remaining paris of
the bone show that they were considerably enlarged before the
carious disposition took place, which has led some to consider it
as a species of spina ventosa of the back bone. Such a state of
the bones often produces bad symptoms and much mischief; but
the curvature cannot take place till the caries has caused a loss of
substance in the bodies of the vertebrae.

The first and great object, in our endeavours to relieve this dis-
ease, must be to prevent the increase or continuance of the caries,
and to give nature an opportunity of restoring the weakened part
by furnishing fresh growth of bony matter. That this effect has
been produced by issues opened on each side of the curvature, has
been proved beyond controversy, by symptoms in the living, and
by examination of the parts after death. Many persons have, in
a great variety of instances, had opportunities of observing the
gradual progress from total imbecility to strength and vigour, with-
out the intervention of any other means than issues; and I feel the
highest satisfaction in having it in my power to assert, that by
such simple means one of the most destructive disorders which
attack the human frame may be prevented, and the blessings of
health restored. To him who invented or proposed the plan,
every praise is due; and I may presume that any attempt to im-
prove on it cannot fail of being well received.

On these grounds I shall take the liberty to remark, that highly
as I think of the power and efficacy of issues in these cases, I must
confess that in many which I have attended, I have been con-
scious of the want of some power, or means, to raise and support
the superior parts, and to take off the superincumbent pressure.
And I have long been of opinion that, in this case, surgery will
find great advantage in the aid of mechanism.

THE LOWER LIMBS. 3T3

The assistance derived from mechanical powers, in a variety of
chirurgical cases, is too notorious lo require to be mentioned: their
effects on bent bones, clubbed feet, and other distortions of the
limbs, must be manifest to any one who will candidly give his
attention to the subject; yet ? from unaccountable prejudices, 1 have
known some eminent practitioners in surgery oppose, even in these
cases, what they call the use of irons, and who would let Nature
persist in her error, in hopes that she may rectify herself in the
general growth of the body, rather than take proper means to
lead her into the right path; while the real state of the fact is,
that the distortion is much more likely to become consolidated with
the growth of the child, and strengthen with its strength, until it
is confirmed and unalterable.

Mr. Pott had no objection to the use of instruments in cases of
distorted limbs: I have many times known them applied under his
direction with great advantage; but he certainly did not entertain a
favourable idea of any assistance to be gained by mechanical
powers in those distortions, or incurvations of the spine, which
were the subject of his treatise; on the contrary, in several pass-
ages of the work alluded to, he showed a marked disapprobation
of them. He was of opinion that the discharge produced by the
issues was all which is requisite for a cure, and so it has certainly
often proved, no other means being employed in cases which have
succeeded perfectly; yet he agreed that other assistant means, such
as bark, cold bathing, frictions, &c, might occasionally be added,
in order to expedite the cure; but with regard to pieces of me-
chanism, as was observed, he always objected to them, and would
not allow them to be in any degree assistant to his plan. I should
certainly be cautious in giving an opinion after such respectable
authority; yet I must observe, that the more respectable an author
is, the more weight his opinions carry; and consequently there is
more reason why those opinions should be scrutinized, if they clash
with subsequent observations apparently well founded. Thus,
with all due deference to the judgment of a man, of whom no one
can entertain a higher opinion, I must observe that I think some
powers of mechanic ingenuity may, in many cases of distortions of
the spine be made, not only to assist in accomplishing the end
which Mr. Pott intended by the caustics, but to produce effects

374 ON THE PALSF OP

more beneficial, and far beyond what he himself expected from
their application.

Mr. Pott observes that " these pieces of mechanism are calcu-
" lated to obviate and remove what does not exist; that they are
" formed on a supposition of actual dislocation, which never is
" the case; and therefore they always have been and ever must be
" useless." I readily allow that in those cases in which the issues
have been so successful, there is no dislocation; but it must be ac-
knowledged that the part occupied by the disease is in general
extremely weak, and incapable of supporting the weight of the
parts above the curvature. On this head Mr. Pott himself re-
marks, that, " if the curvature be of the neck, the child finds it
" inconvenient and painful to support its own head, and is always
" desirous of laying it on a table, pillow, or any thing, to take off
" the weight." The same thing precisely happens when the dis-
ease attacks the dorsal or lumbal vertebrae. Every one who has
attended to these cases, must have remarked the efforts which
children make under such circumstances: I speak of children a&
being most frequently liable to the complaint; but adults, and
every one subject to a weakness in the back, from whatever cause,
endeavour to take off the load which oppresses them, by support-
ing themselves on tables or chairs; and when they rise to walk,
they press their hands on their knees in order to relieve the spine:
all this points out the necessity of giving what assistance is in our
power to the weak part.

In another place Mr. Pott observes, that the bones are already
carious, or tending to become so, the parts connected with them
diseased, and not infrequently ulcerated; that " there is no dis.-
" placement of the vertebrae with regard to each other, and that
" the spine bends forward only because the rotten bone or bonets
" intervening between the sound ones give way, being unable in
" such state to bear the weight of the parts above." Surely then
it appears reasonable that those parts should be strengthened and
supported, while nature, with the assistance of the issues, is doing
the work of restoration, by putting a stop to the caries, after which
bony matter is deposited to supply the deficiency which the dis-
ease has produced. We apply splints to a broken leg while ossi-
fication is forming; we do not allow any pressure to be made on

THE LOWER LIMBS. 375

it while that natural process is going on; and the patient afterwards
takes off the weight of the body from it by means of crutches,
until it is perfectly strong and capable of its own duty. I am at
a loss to find any good reason or sound argument why the same
means of assistance, at least so far as lies in our power, should not
be applied in cases of a weakened spine, in order to take off su-
perincumbent pressure, and to endeavour to restore the actual form
of the spine during the progress of the cure: if this be not attempt-
ed, or cannot be brought about at this time, the consequence must
be that the back will remain crooked during the cure. Nature is
obliged to do her work while it is in the bent position; and though
the strength of the pillar be subsequently increased, the cure itself
becomes in some degree an evil, and a lasting one, as the growth
of new bone in that situation must consolidate all the parts, and
must confirm the curvature exactly, or nearly as it stood, before
the cure was attempted; for whatever power the issues have in
strengthening, it cannot be supposed that they can materially alter
the curve which is already formed. The period when we are
most likely to improve the form of the pillar must be during the
progress of the cure, while the parts allow of some latitude of
motion: when they are once become consolidated and fixed by the
growth of bony matter, no alteration scarcely can take place but
what is effected by the future general growth of the whole body.
In very young subjects this is certainly very considerable; but is
not this an argument why the assistance to be obtained by growth
should as early as possible be determined in a proper direction?
When that is accomplished, bark, cold bathing, and frictions may
be useful; but till then, the aid which they may give only contri-
butes to fix and confirm the parts in a wrong situation.

From repeated observation I am so convinced, and conceive the
benefit likely to result from mechanic assistance so self-evident,
that had not the objections to it originated in an authority so gene-
rally respected, I should think it unnecessary to advance anything
more on the subject. But this being the case, I take the liberty to
add, that as a further proof how necessary it is that by some
means or other the pressure of the parts above must be in many
cases taken off while the cure is perfecting, and to show that Mr.
Pott himself was convinced of the necessity of it. though perhaps

376 ON THE PALSY OF

it did not appear to him exactly in the same point of view, I must
remark, that in many cases of curved spines which Mr. Pott
attended, he thought it necessary to confine his patients to bed, or
to a horizontal, situation during the greatest part of the cure, as
they could not bear to remain in an upright position. I need not
observe how irksome this must be, how it must tend to relax and
weaken the patient, and consequently to retard the cure: seeing
it only in this light, it must be acknowledged that any means
which would render unnecessary this severe and unhealthy process,
must be desirable and advantageous.

That many of the machines which have been invented to re-
medy distorted spines, from having been imperfectly or improperly
made, badly contrived, or injudiciously applied, are capable of
doing much mischief, must certainly be allowed: the neck swing,
and the screw chair, I should conceive, can do little good, for it is
obvious that a posture produced by swinging a child by the neck,
or stretching it in a chair, cannot long be borne: he may be amus-
ed in it at first, but in a short time it will become irksome, if not
painful, and he will be urgent to be released; and then what
good can an extension of such duration have done? The weight
of the superior parts, all the rest of the day, destroys the little
effect produced. If it be often repeated, the alternative of exten-
sion and relaxation must be injurious, as it interrupts the regene-
ration of parts, and by moving the diseased bones on one another,
is a constant source of irritation. In some cases, when the parts
are already weakened by the disease, much mischief, even to fa-
tality, maybe the consequence of imprudently or violently stretch-
ing them. The stays, which are intended to apply forcible pres-
sure to the prominent part of the curve, are also in my opinion
inefficacious, and sometimes detrimental: but if a machine be con-
trived to elevate the head, and support the thorax, passing down
the spine, and strengthening it, as a splint does a broken limb, resting
on the pelvis, as its basis, with a connivance to give such gradual
and permanent extension as the weak parts will bear without in-
jury, and to be continued until, by a deposition of osseous matter,
the yielding vertebrae become firm and compact bones, I am
clearly of opinion that much good from it may be derived.

THE LOWER LIMBS. 377

This instrument has received still further improvements, which
in some cases have been found necessary and efficacious, particu-
larly when there is also a diseased state of the bones of the pelvis.
It has been contrived to pass under the arms, and to rest on the seat,
so as to take off the whole weight of the body when sitting: it has
also been connected, by means of joints, to perpendicular bars,
passing down the outside of the thighs and legs, to support it when
in a standing posture.

The want of some assistance in aid of Mr. Pott's plan always
appeared to me in a strong light, and I was induced to give my
opinion on it more at large, in a pamphlet, published in 1799, of
which this is an extract.

Indeed, the good effects arising from a well adapted instrument
in cases of curvature, from various causes unaccompanied with
caries, is so generally known and acknowledged, that it is unne-
cessary to say more on the subject in this place: what I principally
wished, by the description of it in the pamphlet alluded to, was to
show that it is safe and useful, and to endeavour to set aside the
disinclination which I perceived in many practitioners, as well as
in the writings of Mr. Pott, to admit of its use or assistance in
cases of curvature, attended with caries; and further, I have en-
deavoured to make it apparent, that such a contrivance is not only
frequently useful, but often absolutely necessary. I need not ob-
serve that undoubtedly greater care and judgment are required in
the application of it, where some of the bones of the spine being
carious, the parts connected with them may more easily be injured
by improperly or suddenly stretching them, than when the curve
has arisen from muscular action or other causes.

But I hope not to be misunderstood: I do not mean to say,
indeed am far from thinking, that instruments of any sort are
wanting in every case of curvature of the spine. The issues are
often sufficient to complete the cure without any other assistance,
as has been proved in many instances.

Mr. Pott has, in his usual perspicuous manner, given a circum-
stantial account of the method of applying the caustics and con-
ducting his mode of cure; but as some alterations have since been
introduced which appear to be improvements on his plan, I think it

VOL. II. 3 B

3"J8 0N THE PALSY OF

right to notice them. Mr. Pott has directed the issues to be made
of an oval shape, and has left a sketch of one, as a pattern, one
inch long by three quarters of an inch wide. From repeated ex-
perience I have found longitudinal eschars, according to the extent
of the curve, answer better. They should be made so that the
peas may lie imbeded on each side, and near to the spinal pro-
cesses. Particular attention should be given that the caustics be
applied so as to reach just above the curvature. I have many
times seen a large and copious drain maintained without effect,
because it was made below the beginning of the curve; but, on its
being opened above, the good effect derived from it soon took
place. If peas or small beans are used, they should be softened
by soaking them in water: they should then be strung on a thread
and suffered to dry, when they are to be cut into proper lengths
according to the drain, which, as was observed, must vary with
the circumstances of the case: thus they are easily applied and
easily removed. It has always been no small difficulty to keep
these issues open and in a good state, so as to furnish a proper
discharge. The means which have been usually employed for
this purpose are painful, and the effects produced by them of
short duration; so that the issues were perpetually closing and
filling up with fungous granulations, in consequence of which the
unpleasant task of using escharotics became necessary, at least
once a week, or oftener in some subjects. This in adults was
often as much as they could bear; in children particularly distress-
ing to every one concerned. At some intervals this was neces-
sary to be done with fresh application of caustic, perhaps more
painful than the original one.

Very small solid glass beads, placed all round the edges of the
wound, have of late years been found to obviate these difficulties,
for wounds never heal from the centre; and if the beads are pro-
perly applied, they will soon sink in beneath the granulations;
and being foreign bodies, the sides of the wound will never heal
over them. Another advantage which the beads have over peas,
is, that when once they are fairly established, they may be left in,
and the issues may be dressed like other superficial wounds;
whereas peas or beans swell, and require to be daily renewed, as.
being vegetable productions, they soon become putrid.

THE LOWER LIMBS. 379

I have sometimes used setons, and in some cases am inclined to
give them the preference for several reasons: they embrace a large
extent, which is of material consequence when the diseased part
cannot be very accurately determined, or where there is reason to
suppose that several vertebrae may be affected: they become effi-
cient in three or four days, when the sloughs from the caustics do
not separate generally in less than a week or ten days: they are
not offensive; and they never need the application of escharotics,
except at the extreme points from which only fungous granula-
tions can arise.

The object is to procure a large discharge of matter by suppu-
ration from underneath the membrana adiposa on each side of the
curvature, and to maintain it until the cure be accomplished, or
so long as may be thought necessary. Whether this be brought
about by issues or setons is perhaps 'not very material, but the
easiest means will always be the best. Mr. Pott disliked setons:
he observes, " A seton is a painful and nasty thing; besides which,
" it frequently wears through the skin- before the end for which
" it is made can be accomplished." In the common way of
making and managing setons this was certainly the case; the
usual mode was in general to make the track of the seton short,
but, be the length what it might, the silk, or whatever it was
thought proper to use, was passed through and cut off an inch or
two above and below, and a knot was fastened at each end, to pre-
vent it from slipping out. This was ordered to be moved every day
backward and forward, and the wounds at each end to be made
clean; but the seton was not changed, so that it constantly re-
mained in the wound, immersed in, and confining a quantity of
putrid matter, the acrimony of which certainly tended to inflame
the skin, and made it wear its way out: but under different ma-
nagement I conceive the effect produced will be very different.
The method I would recommend is the following.

A seton needle being passed in the usual manner through as
great a space as may be deemed necessary, will conduct a skein
of coarse silk, which, when brought out at the lower wound, should
be cut off from the needle, leaving about an inch to be secured
by a slip of sticking plaster, to prevent its being drawn back
ngain. The remainder of the silk above should be neatly doubled

380 ON THE PALSY OP

up, and confined by a slip or two of sticking plaster. When the
suppuration is established, and the seton become loose, it may be
drawn down. The part which is soiled by the matter may be cut
off, and a fresh portion of silk introduced. When one skein is
used, another may be connected to it, and drawn through in the
same manner. Thus it may be changed as often as necessary,
and the wound be kept perfectly sweet and clean. By these means
the skin will not become inflamed or irritated, and the drain may
be continued almost for any length of time.

I have frequently remarked that the first action or stimulus of
the caustics produces an almost immediate effect; the patients, in
a day or two after they are applied, find a considerable alteration
for the better in the general state of their health, attended with a
glowing warmth, and sometimes a degree of motion in the limbs.
I have often pointed out this at the Hospital, at the same time ob-
serving that this agreeable symptom would soon be less apparent;
nor until the issues should arrive at a more advanced stage, would
any permanent good effects be observed; and my conjecture has
seldom proved unfounded. I mention this, that people may not be
discouraged at experiencing this kind of check upon their hopes:
let them wait with patience till the drain is fairly established, and
they will rarely be disappointed in their expectations.

Parents, nurses, and persons unaccustomed to these cases,
dread the quantity of the discharge, and conceive it must tend to
weaken the constitution; but it certainly has not such an effect.
I have often remarked children improving in health and strength,
and growing fat under a very considerable drain of this sort. I
do not mean to say that this is the cause of the amendment; the
return of health probably arises from the stop which is put to the
ravages of the disease; and I only mean to infer that neither health
nor strength appears to be diminished by the discharge, which it
is necessary to keep up in order to effect a cure.

Mr. Pott has remarked that " there can be no curvature from
" within outward, without an erosive destruction of the bodies of
" some of the vertebrae; but that there is not infrequently caries,
" without any curvature being produced; that this happens more
"frequently in the loins than in any other part of the spine; that

THE LOWER LIMBS. 381

" what are called lumbar or psoas abscesses are not uncommonly
" produced in this manner; and that a caries of the spine is more
" usually a cause than an effect of these abscesses." That caries
of the bodies of the vertebrae may produce bad symptoms, and may
cause great mischief, before it has destroyed sufficient of ilie bony
support to make the spine bend, is not only probable but a fact
well known. Not only abscesses are produced by it, but it is fre-
quently accompanied with grinding, deep seated pains in the pel-
vis and thighs, sometimes to such a degree as to produce an ina-
bility of motion in the limbs, bordering on paralysis, but not to
such a degree as when the bones have given way, and caused a
compression on the spinal marrow. It is reasonable to conclude
that the same means which are known to cure a disease in its ad-
vanced state, would be more likely to prove efficacious in stopping its
progress in the beginning; but Mr. Pott has remarked, that a when
" these complaints are not attended with an alteration of the
" figure of the back bone, neither the real seat nor the true nature of
" such distemper is pointed out by the general symptoms, and con-
" sequently that they are frequently unknown, at least while the
u patient lives.' 1 '' This is an observation of material import, and
should not be passed by without a comment, as it rather tends to
damp our inquiry into this species of mischief, the progress of
which might often be arrested, if found out in time. It may be
right therefore to observe, what from repeated instances I have
learned, that, in cases which have led to a suspicion of the pro-
ducing cause being derived from the back, if we attend to the pa-
tient's complaints, and observe the part to which he points, the seat
of the mischief may often be discovered, by pressure with the
lingers, or tapping with the knuckles gently on each vertebras,
singly, one after another. I need not repeat that this is a fact of
great consequence to be known, as when discovered, the incipient
disease may often be stopped; and probably many lumbar abscesses,
with all the consequences of increase of mischief, may be pre-
vented.

The following case will serve to illustrate this point of practice:

In April. 17.95, Mrs. F , a lady from Ireland, consulted

Dr. Turton on account of pains, with which she was afflicted

382 ON THE PALSY OF

about the lower part of the loins and hips, which were thought to
be rheumatic. As she received no relief from medicine, and there
was some inability to walk, Dr. Turton, with his usual acuteness
of judgment, suspected that her complaints might arise from some
disorder in the spine. I was accordingly desired to examine it; I
found the spinal processes of all the vertebrae perfectly regular and
even, and could discover no reason to suppose that the disease had
its source from that origin. On its increasing, I was desired to
meet the doctor again. She was now considerably worse, her
pains in bed were tormenting and almost constant: with great dif-
ficulty, and not without the assistance of a servant, she could drag
one foot after the other across the room. I again examined the
spine, and could discern not the smallest deviation from the right
line; but, on pressing pretty firmly on every vertebras singly, I ob-
served, when I came to the two lowermost of the loins, she
shrunk from the touch, and said, in that part I gave her a
sensation she had not felt before, amounting to pain, though
not acute. From these observations alone, it was determined
to apply caustics on each side of those vertebra?, the sur-
prising and happy consequence of which was, that in a few
nights her pains grew better, and soon in a great degree left her.
In a fortnight she was able to walk without assistance across the
room: soon after she went into the neighbourhood of Hampton-
Court, where her health and strength improved rapidly, and in
about two months she was able to walk a couple of miles. In the
autumn I saw her at Brighthelmstone, where she bathed, walked,
rode on horseback, and enjoyed good health and spirits; and I may
add, that I afterwards met her frequently in London, where she
spent the winter, without any return of the complaint.

Many more instances might be adduced when the cause, though
occult, has been discovered, and the mischief, which we may posi-
tively conclude would have gone on from bad to worse, has by the
assistance of caustics been restrained and prevented. If any doubt
should arise about the precise spot where they should be applied,
the caustics, if it be thought proper to use that method" not being
confined to small oval ones, but made longitudinal, so as to take
in one or more of ihe vetebrae, according to circumstances, will be
the means of findi ng out the disease and acting upon it; or if setons

THE LOWER LIMBS. 383

are used, they may be made sufficiently long to include with cer-
tainty the seat of the disease.

In the latter part of Mr. Pott's life, he had applied the method
of cure by issues to other diseases: particularly in strumous affec-
tions of the joint of the hip, he had been several times successful
in preventing an increase of caries, by means of an ulcer being es-
tablished in the neighbourhood of it. In those deplorable cases,
where one hip is let down below the other, where the parts are flab-
by, the glutaei muscles lose their firmness, the buttock its figure and
convexity, and the leg is lengthened, probably by the increase in
size of the head of the os femoris, he found that the progress of the
disease may frequently be stopped, and the parts restored to their
natural firmness arid figure, by making an issue just behind the
great trochanter. Mr. Pott remarked that the time when the
change will take place, and the restoration be complete, is indefi-
nite: it may take place in a few weeks or months: or, as was ob-
served with regard to the effect of caustics in diseases of the spine,
it may require a much longer time. In short, every thing relative
to the complaint is uncertain, except the ultimate cure, which will
rarely fail to reward our perseverance; provided, that at the same
time the constitution is attended to, and the diseased habit of body
corrected by medicine, proper diet, and good air.

When the thigh was retracted, and accompanied with a consi-
derable swelling, Mr. Pott was not sanguine in his prognostics of
recovery, but spoke of most applications as inefficacious. Yet,
even in these cases, I have known the caustics applied with great
apparent advantage.

Some years ago I was desired by the late Mr. Berry to visit a
girl about eighteen years of age. She complained of pain in her
knee, leading up toward the hip; she could not straighten her
thigh, which was drawn up toward the pelvis, and with great dif-
ficulty she could walk across the room; she had been electrified,
and had used variety of remedies, by the advice of some gentle-
men of eminence in the profession, to no purpose; the complaint
grew rapidly worse, and she was obliged to take to her bed. The
thigh was now drawn up to the pelvis, the knee turned inward,

384 ON THE PALSY <TF

and the appearance was as if the head of the femur was dislocated;
the parts surrounding the hip were turgid and enlarged, exquisite-
ly painful to the touch, and on the smallest motion; blisters, em-
brocations, fomentations, &c. Were tried in vain. The pain was
now become almost incessant, the disease continued to increase,
and bore the appearance of matter forming in the joint. Though
this was not a case in which Mr. Pott recommended an issue, I was
determined to give her the chance of one: a caustic was according-
ly applied below and posterior to the great trochanter. She did
not appear to be much served by it at first, though we remarked
that her pain was not so violent: in about six weeks she seemed to
have derived some benefit, and though the limb was still contract-
ed she could straighten it better. I now found that the issue had
been neglected and nearly suffered to close. I recommended it
to be enlarged, which was done the beginning of September: in
about a week after, when the suppuration was fairly established,
she began to grow better, the joint became unlocked, and in a few
weeks she had lost the pain of the hip, and was able to straighten
the thigh and leg perfectly; soon after she walked across the room
without help, only complaining of a little tenderness in the joint,
and in no great length of time afterward was perfectly recovered.
No other method having been of the least service to her, as she ap-
peared to receive some advantage from the first application of the
caustic, and got well after the repetition of it, we may reasonably
infer that they were the causes which produced the alteration and
subsequent cure. As this was the first case of the kind I had tried
it in, I regarded it with some degree of diffidence, but have now
no doubt of the fact; as I have since seen several cases nearly si-
milar, and have one at present under my care, which have received
great benefit from the application of caustics. In those cases in
which Mr. Pott succeeded, a much longer time elapsed before the
effect was produced.

Mr. Pott also used caustics in scrophulous swellings of the joint
of the knee, where there was suspicion of beginning caries: they
were applied just above and below the joint: in some cases they
appeared to be materially serviceable in preventing the increase
of the swelling; in many others they failed.

THE LOWER LIMBS. 385

In similar diseases of the joint of the ankle he also tried them:
but the caustics seemed to have less effect, as the part affected was
at a greater distance frem the trunk: in these joints no advantage
appeared to be derived from them. The idea, however, is wor-
thy of its author, and deserves further trials; indeed, whatever has
the least chance of being beneficial ought not to be neglected in
those desperate cases, which, if their progress be not prevented,
terminate in the unavoidable loss of the life or limb. E.

vol. II

3 c

AN

ACCOUNT OF TUMORS

WHICH RENDERED

THE BONES SOFT.

COMMUNICATED TO THE ROYAL SOCIETY,
BY MR. POTT, SURGEON;

>SD PRINTED Vf THEIR TRANSACTIONS, VOL XI*

AN

ACCOUNT OF TUMORS

WHICH RENDERED THE BONES SOFT, &c. &c. &c.

In November 1737, a gentleman aged 27 complained to me of
a swelling in the inside of his right thigh (being in every other re-
spect in perfect health). Upon examination, it appeared to be an
encysted tumor of the steatomatous kind, lying loose between the
sartorius and vastus internus muscles. I told him I could propose
no way of curing it, but by taking it out; which was accordingly
done, and he wa* very well in six weeks.

After this he continued well for near a year, (except that he now
and then complained of a slight pain in the joint of that hip, which
went off and returned at different times,) and then fell into such a
disposition to sleep, that no company or diversion, nor his own
endeavours to the contrary, could keep him awake, after eight or
nine o'clock in the evening, if he sat down.

This continued on him for three or four months, and then the
pain in his hip grew worse; for which he used the cold bath, flesh
brush, and riding on horseback, but without any effect.

Hereupon he asked the advice of Dr. Beaufort, who put him into
a course of aethiops mineral, cinnabar of antimony, and gum
guaiacum, with the Spa water, and purging with calomel by
intervals. This method he pursued for a considerable time, but
without any benefit.

390 AN ACCOUNT OP TUMORS

After this, by the advice of some acquaintance, he took half a
drachm of salt of hartshorn, night and morning, in a draught of warm
whey, for some time, but without any sensible effect, even by
perspiration.

Some little time after this, he began to complain of a slight
periodical heat and thirst, which returned every night, with a quick
hard pulse, but which was not so great as to make him uneasy.

It was now September 1739, when, having an opportunity of
going with some friends, he determined to try what Bath would do
for him: in his journey thither, the nocturnal heat and thirst in-
creased so much as to prevent his sleeping; but in the few days that
he spent in recovering from the fatigue of the journey, they seemed
to go off again.

He then began to use the waters, both internally and externally;
upon which the last mentioned symptoms again appeared, and he
was obliged to desist, and use cooling medicines.

His physicians then advised him to bathe the affected limb only,
upon which they returned again, and with such violence, that the
further use of the waters was thought highly improper, and he then
left them off.

During this time the sight of his left eye grew dim, which dim-
ness increased gradually for some little time, till he became quite
blind of that eye; the bulb of it being considerably enlarged, and
thrust forward out of the orbit.

For the most part of the time he had been at Bath, he had gene-
rally been very costive; and upon leaving off the water, had no
stool for some days; for which reason a common clyster was given,
and produced so profuse a discharge of serous matter, and con-
tinued for so many hours, (almost incessantly,) that he was reduced
as low as possible.

For some time past several small tumors had appeared in dif-
ferent parts of him; viz. five or six on his head, two or three in his
back, and one in the neck; all lying just under the skin, and
sensibly increasing every day, till they came to a considerable
size.

December the 2d, 1739, he returned to London.

His chief complaints now were an excessive langour, an inability
to move his right hip, and, when moved by another person, a very

WHICH RENDERED THE BONES SOFT. 391

acute pain in it, an incapacity of sleeping when in bed, and an
intense thirst in the night, with a quick hard pulse.

He now took the advice of Dr. Hartley and Dr. Shaw, who
prescribed him the cinnabar of antimony three times a day, to
drink the Seltzer waters, and keep to a cooling regimen; and
allowed him a moderate dose of the pill Matthaei every night; by
means of which he got some sleep, of which he had for some time
been absolutely deprived.

When he had taken the cinnabar five or six days, and during
that time had no stool, it was thought proper to give him a clyster,
which brought away all the medicine, without the least alteration;
nor was there ever after this time any appearance of any mucus
being secreted by the intestinal glands, he never going to stool above
once in a week; and then there came away a few lumps of excre-
ment as hard as pieces of wood, which were expelled with such
labour and fatigue as can hardly be imagined, though he generally
took an oily clyster to render it more easy, and washed down his
medicines with a soapy draught.

The joint of the hip was now become quite stiff, all the inguinal
glands being loaded with the same kind of matter, of which the
other tumors seemed to be composed; and a large cluster more
of them might be felt under the glutaei muscles, and behind the
trochanter.

The cinnabar was now left off, and mercurial unction proposed
and consented to; and accordingly a proper quantity was rubbed
in every night, stopping now and then to see what turn it would
take; and in this course he continued for more than a month, but
without any benefit; nor did the mercury produce any visible effect
on him.

Sir Edward Hulse, being called in, directed the burnt sponge,
which he took for some time, till growing worse and weaker he
determined to try Mr. Ward.

He took his sweating and purging medicines two or three
times, but found no sort of effect from them; and being now quite
tired of physic, and reduced extremely low, he determined to pass
the rest of his time as easily as he could, by gradually increasing
his opiate; and in this manner languished, incapable of stirring or
helping himself, till the 2d of May, 1740, and then died.

392 AN ACCOUNT OP TUMORS

For a considerable time before he died, he was nourished by
fluids only; yet, as soon as ever they were received into the sto-
mach, in however small quantity, they gave him an acute pain at
the bottom of his belly, just above the pubis.

For two months, or more, before his death, he could never
make any water while he was up, but always made a good deal
at different times when in bed.

Soon after his return to London I opened the tumor I had
taken out of his thigh two years before, and found the inside of it
ossified.

Upon dissection, the first thing that offered itself was a large
tumor on the sternum, which had been perceived about three
months before he died: it was as large as a turkey's egg, and so
hard and immoveable, that I was in doubt whether it was upon
or under the bone.

Upon removing the skin, it appeared covered by the expansion
of the tendons of the intercostal muscles, and the periosteum: this
coat being taken off, it was of a suetty kind of substance for about
half an inch deep; and below this was a kind of cartilage inter-
mixed with a great many bony particles. I then shaved off all
this diseased body even with the surface of the rest of the ster-
num but found no bone, it being quite dissolved and confounded
with the mass of matter that composed the tumor, which was
equally protuberant within the thorax, and composed of the same
materials.

Part of the fifth and seventh ribs were dissolved in the same
manner into a kind of substance between bone and cartilage, with
a thick coat of steatomatous matter.

Within the cavity of the thorax were thirty-seven of these dis-
eased bodies, most of them attached either to the vertebrae or the
ribs; and wherever they were attached, the cortex of the bone
was destroyed, and its internal cellular part filled with the dis-
eased matter.

Immediately above the diaphragm was a large scirrhous body,
lying across the spine and the aorta, the latter of which lay in a
sinus formed in its lower part: it had no attachment to any other
part, and weighed thirteen ounces and a half: and from its situa-

WHICH RENDERED THE BONES SOFT. 393

tion, I think, must have taken its rise from some of the lymphatic
glands lying about the thoracic duct.

From the origin of the aorta, from the heart quite up to the
basis of the cranium, all the blood-vessels were surrounded with
these scirrhous bodies, and the thyroid gland was diseased in like
manner, and bony within.

On the left side' was another of these bodies, made out of the
glandula renalis, weighing nine ounces and three quarters.

On the right, the giandula renalis was in a natural state; but
the cellular membrane, which surrounds the kidney, was filled
with a large cluster of these bodies of different sizes, some of them
entirely suetty, others intermixed with bony particles. Three or
four of them were attached to the body of the kidney, and these
were a sort of cartilage, beginning to ossify.

The pancreas was quite scirrhous and very large.

One very large tumor sprung from the spongy body of the third
vertebra of the loins; the bony texture of which was so dis-
solved, and mixed with the matter of the tumor, that the knife
passed through it with great ease.

The inner side of the os ilium, all the ischium and pubis, were
covered with these appearances; and, upon removing them, the
bone was found in the same state as the sternum and ribs; the
middle of the right os femoris was surrounded with a mass of the
same matter, and the bone underneath in the same state.

In the bottom of the orbit, surrounded by the recti muscles, was
a pretty large steatoma, which occasioned the protrusion of the
eye; and, by pressing on the optic nerve, (in all probability,) the
blindness.

VOL. II. 3 D

AN

ACCOUNT OF A HERNIA

OF THE

URINARY BLADDER,

INCLUDING A STONE;

COMMUNICATED TO THE ROYAL SOCIETY,

BY MR. POTT, SURGEON;

AND READ FEB. 16, 1764.— INSERTED IN THEIR PHILOSOPHICAL TRANSACTIONS,
VOLUME LIV.

AN ACCOUNT, &c. &c.

A healthy boy, about six years old, was suddenly seized with
a most acute pain at the bottom of his belly: during the time he
pain lasted he could not discharge a drop of urine, though he fre-
quently endeavoured. After about an hour and a half, he became
perfectly easy on a sudden, and pissed very freely. A few days
after this, a small tumor, about the size of a large pea, was disco-
vered, in the upper part of the spermatic process, just below the
groin. As this tumor was perfectly indolent, and gave the child
no kind of uneasiness, no notice was taken of it. By slow degrees
it descended lower and lower; and, as it descended, it seemed to
increase in size: the boy was observed to make water oftener than
usual, but without pain or difficulty. He was looked at by two or
three practitioners in the country, who, not knowing what to make
of it, advised the letting it alone: at last, in the space of five years,
it got to the lower part of the scrotum; and, after it was got thi-
ther, it was observed to increase in size much faster than it had
done before. The boy was at a great distance from London, and
his friends could ill bear the expense of going thither with him;
so that another year passed away after the tumor was got into the
last mentioned situation. At last, when he was about thirteen years
old, the swelling becoming troublesome, and the people in the
country not caring to meddle with it, he was brought to London.

Two or three gentlemen of the profession, to whom he was
showed, took it for a scirrhous testicle, and advised the extirpa-
tion of it; to which the child's friends would not consent.

When he was brought to me, I examined him very carefully,
and was satisfied that the tumor, (which was now about as big as
a middling chesnut,) was not formed by the testicle; but, though

398 AN ACCOUNT OF A HERNIA

I was clear that it was not formed by that gland, yet I could not
find any testis on that side.

The swelling was still perfectly void of pain; had a stony, in-
compressible hardness; was troublesome to the child when at. play,
or using any brisk exercise, but never gave him any uneasiness
when he sat, or stood still. It had all the appearance of being
dependent from the spermatic process; but the process, though it
had neither the look nor the feel of being diseased, was yet too
large and too full for a child of that age, and larger and fuller
than that of the other side. The perfect equality and smoothness
of the tumor, its extreme incompressibility, and its being perfectly
free from pain, even when pressed with some force, were the cir-
cumstances which induced me to believe that it was not the tes-
ticle; but though I was, in my own mind, satisfied of that, yet I
cannot say that I was by any means clear what it was; and all that
I could determine was ? !hat it certainly ought to be removed; as
well on account of the trouble it now gave, and its manifest dis-
position to increase, as that I could not foresee any great hazard
that was likely to attend its extirpation. From the uncertainty in
which I was concerning the true nature of the case, I determined
to act very cautiously. I made an incision through the skin and
cellular membrane, from the upper part of (he scrotum quite down
to the lower; by which I discovered a firm, strong, white mem-
branous cyst, or bag, connected loosely with the skin by means
of the dartos; I dissected all the anterior part of this cyst quite
clean; and found that, as I traced it upward, it became narrower,
and seemed to proceed from the groin: this determined me to try
if I could not free the posterior part of it also. In doing this I
discovered the testicle, which was much compressed, flat, very
small, and lay immediately behind the tumor.

The dissection of the testicle, and of the spermatic chord from
the bag. and from its neck, (which I was obliged to do in order to
preserve the testis,) took up some time, and gave me some trou-
ble; but when I had finished it, I found that the cyst was depend-
ent from, or continuous with, a membranous lube, or duct, of
about the breadth of a large wheat straw, which seemed to pass
out from the abdomen, through the opening in the oblique muscle,
along with the spermatic vessels.

OF THE URINARY BLADDER. 399

When I had perfectly freed this duct from all connexion, I cut
it through immediately above the tumor: upon the division of it a
quantity of limpid fluid (not less than two ounces) followed, and
the mouth of the cyst expanding itself discovered a large stone,
exactly resembling the calculi found in the urinary bladder; which
stone was closely embraced by the said cyst.

As there was not the least appearance of any fluid either in
the bag or duct, before it was cut off, this discharge, together with
the stone, induced me to suspect that the case was a hernia cys-
tica. In order to be certain, I staid some time; and, when I
thought it was probable that some urine was derived into the
bladder, I desired the boy to make water: he endeavoured so to
do, and a full stream of urine flowed out through the wound in
the groin, which put the case beyond all doubt.

I dressed him superficially; he had no bad symptom; his urine
all passed out by his wound for a fortnight, or twenty days; at the
end of which time, the wound gradually contracted; all the urine
came through the urethra; and at the end of a month he was per-
fectly well.

OBSERVATIONS

HEMORRHOIDAL EXCRESCENCES.

BY THE EDITOR.

VOL. II. 3 E

OBSERVATIONS, §c. §c.

In the account of Mr. Pott's life, prefixed to my edition of his
works, I asserted that he had been remarkably successful in the
treatment of those painful excrescences which are produced from
within the verge of the anus, and the removal of which, when
large, firm, and indurated, has generally been thought dangerous
and unadvisable. Mr. Pott had entertained a design of writing
on this subject, to lessen the apprehension of practitioners, by
pointing out in what cases an operation may be safely performed.
The method which he employed was not new: it has been de-
scribed and recommended by writers, and has been frequently
practised on piles in a small and flaccid state; but he often as-
serted he knew no one who would attempt to apply it to the ad-
vanced state of the complaint: as far as my experience leads me,
I believe his assertion strictly founded, or if it be practised by
some, it is by no means generally adopted. During the last ten
years of Mr. Pott's life, he had many opportunities of performing
this operation: most of the patients I attended with him, and found
that several of them had previously consulted other eminent sur-
geons, from whom they had not met with a proposition for a radi-
cal cure; in others the disease had been absolutely abandoned as
an incurable cancer. For these reasons Mr. Pott often remarked,
that he thought it a subject well worthy of being brought forward
for the consideration of practitioners.

It is certainly a disease which, whoever labours under, must en-
dure a miserable existence; consequently, every attempt towards
the relief of it must be proportionably valuable; and as the sub-
ject had escaped Mr. Pott's superior pen, I thought some account

404 ON HEMORRHOIDAL EXCRESCENCES.

of it from the editor of his works would not be unacceptable: it
was therefore inserted in my former edition, as an appendix to
his Treatise on the Fistula in Ano. By some accident it has been
omitted in this; but as it still appears to me too important to be
left out, I have thought proper to subjoin it in this place. My
description, however, only professed to give a sketch of the com-
plaint, and an account of Mr. Pott's method of treating it; and at
present I see no reason for altering my plan, as it appears to me
sufficiently to point out the leading characters of the disease, and
those circumstances in the operation which chiefly deserve atten-
tion.

The intestinum rectum is well known to be subject to a variety
of diseases, from various causes; from its structure, use and office;
and from its situation, which renders it liable to be pressed upon
by the whole power of the abdominal muscles: it is also sensibly
affected by its connexion with other parts in its vicinity, and it
often affects them.

The diseases we are to treat of are tumors, originally formed
within the rectum, and produced by a distention of the hemorr-
hoidal vessels: in this state they are considered as inward piles,
and give little trouble or uneasiness. In more or less time the tu-
mors, being increased in size, are forced down in going to stool,
and return back when the abdominal muscles cease to act. Soon
after, grown larger, they return with difficulty, and require a con-
siderable time and pressure before they will return: by degrees
they are more irritable and painful to the touch; at length they
become indurated and stationary, and are not to be reduced by
any means, but are extremely inconvenient, and painful in the
greatest degree. In some cases, while they are in this situation,
the sphincter ani binds so tight round their basis as to produce a
mortification of them, and thus effects a natural cure, analogous
to that which we recommend — but certainly attended with much
more pain and danger.

These tumors, on their first production, contain nothing but co-
agulated blood; perhaps this blood, at first either stagnating in the
hemorrhoidal vessels, or possibly effused under the internal coat
of the rectum, may, in time, become organized. This organic mass

ON HEMORRHOIDAL EXCRESCENCES. 405

being irritated by frequent and severe pressure, may enlarge, anil
become firm and fleshy excrescences: in this state they frequently
furnish a disagreeable sanies, or bloody discharge, and acquire an
irritated, malignant appearance.

There are other tumors produced in this part, from various
causes; as an enlargement of the sebaceous glands, at the verge
of the anus, and excrescences arising from a venereal or cancer-
ous disposition in the habit, which, in general are easily distin-
guishable from those here described.

The venereal verrucae or excrescences are a frequent symptom
of that poison, and are well known to practitioners. They differ
in every respect from the tumors we treat of: the basis of them is
generally broad; they do not arise from the intestine, nor particu-
larly from the verge of the anus, but indiscriminately from thence
and from the skin in the neighbourhood. They are rather flat than
elongated; they may be tender to the touch, but, unless when ex-
asperated by stimulating applications, are seldom productive of
pain. In females, the same species of excrescence frequently sur-
rounds the anus, covers the external parts of the labia pudenda
and the internal of the thighs, seeming to be propagated in moist
parts by contact; by neglect they sometimes spread over the groins
and pubis, making a large fungous mass, separable into distinct
excrescences. It is useless to attempt the removal of them, until
the poison be eradicated from the constitution; when, though some-
times obstinate and liable to reproduction: they may generally
be made to shrink away by proper topical applications.

Those which arise from a cancer within the rectum, and being
thrust out, appear externally, are more liable to be confounded
with the complaint I mean to describe, as they resemble each
other in many circumstances: both are hard, swelled, and painful;
both at times furnish a disagreeable sanious discharge; in both
cases the patients have the same leaden, pallid countenance.
There are, however, some leading features of distinction which
may be noticed: in the cancerous protrusions the basis is generally
harder, more incompressible, and broader; and has its origin
higher up in the rectum, commonly occupying the whole circum-
ference of the intestine, which so straitens the passage that the
faeces are expelled with difficulty, and are compressed into a flat

406 ON HEMORRHOIDAL EXCRESCENCES.

or angular form. In the cancerous affection of the rectum, the
parts sometimes feel soft, like a rotten substance. The pain of the
cancerous, or malignant fungi, is unremitting: whether they are
external, or returned within the sphincter, the patient is never at
perfect ease, but complains of shooting pains in the region of the
loins.

The pain attending the hemorrhoidal tumors is sometimes great
while they are external; but when this arises from the stricture of
the sphincter, if they can be returned within the rectum, it soon
ceases. When they have been long protruded in an unreturnable
state, by degrees they become accommodated to frequent pressure;
and unless irritated by an access of inflammation to the constitu-
tion, from exercise, wine, improper food, or other causes, they are
commonly not so painful as at their first exit.

In both species of tumor anodyne injections give ease, but less
in the cancerous: the return of pain also in the cancerous tumor is
more immediate, more violent and lancinating. In the present
state of medical knowledge, we are confined to a description of this
dreadful disease: any chirurgical attempt to remove it, would but
aggravate the mischief.

A protrusion of the rectum is also not an uncommon complaint
in persons of a debilitated constitution. People who have accus-
tomed themselves to aloetic purges, are particularly subject to this
complaint; and it is sometimes only a symptom of a generally re-
laxed state of the internal coat of the intestine, through the whole
extent of the canal; in which case lime water, joined with the
bark, has been found to be very materially serviceable. This
complaint may often be entirely removed by anodyne clysters;
but astringent applications to the part frequently do harm.

Fortunately the procidentia ani is not easily confounded with
the complaint we are now considering. The two diseases are
perfectly distinct; the one is a protrusion of the gut; the other is
an excrescence or enlargement of the vessels at the verge of the
anus, protruded in many distinct portions or lobes; of a dark,
dusky red colour; and in every respect different from the proci-
dentia above mentioned.

When, by long continuance, and repeated irritations, these
tumors are_ formed into large unreturnable excrescences, nothing

ON HEMORRHOIDAL EXCRESCENCES. 407

but the hand of surgery can give relief: this is the state of the com-
plaint, in which I think the practice of Mr. Pott deserves our
attention. However large and formidable the appearance of the
excrescences, if there was no symptom of cancerous malignity,
nor any contraindication in the constitution or habit of the patient,
Mr. Pott always recommended the removal of them. Having
seen profuse and dangerous haemorrhages from the use of the knife
in these cases, particularly in one instance, in which the patient
nearly lost his life, he always preferred the ligature. The fol-
lowing was his method of performing the operation: — When the
patient, by straining, as if going to stool, had forced out the tumors
as far as could be done, he laid hold of one of each tumor or
lobe, separately, with a blunt double hook, and drew it gently out-
wards until he discovered the basis of it, which is usually smaller
and less indurated than the part which has been exposed to friction:
then giving the hook to be held by an assistant, he slipped a liga-
ture, previously tied in a loose knot, as near to the basis as possible.
When he was satisfied that the ligature comprehended the whole
lobe, he drew it tight, taking particular care to discriminate be-
tween the natural skin and the tumor: none of the former, however
elongated, should ever be included in the ligature; for, when the
tumor is removed, this will corrugate, and retire to its proper
place, while the loss of any considerable portion of it, by contract-
ing and straitening the parts, would create an inconvenience
severely felt in riding, or any other exercise, and also in the natu-
ral functions of those parts. In the same manner Mr. Pott pro-
ceeded to treat the remainder of the lobes, one after another, taking
care not to include more in each ligature than was necessary: if
the basis was very broad, a circumstance which seldom happened,
he passed a needle, armed with a double ligature, through the mid-
dle, and tied them on each side.

In this manner I have seen him treat successfully several cases,
in which the tumors had increased to a considerable magnitude,
particularly two, where they were at least from eight to ten inches
in circumference: they had been of long standing, and were ex-
quisitely sensible. The patients had long been in a state of hope-
less misery, almost wholly excluded from society, debarred from
all exercise, and not able to sit but in a chaise jpertfe: the appear-

408 ON HEMORRHOIDAL EXCRESCENCES.

ances in both these cases were very similar, from the turgidity, at
first sight uniform; but on examination they were divided into
distinct tumors; which Mr. Pott carefully separated; and treated
as has been described. The operation succeeded perfectly well
in both; and from that time neither of the patients has experienced
the least inconvenience, or return of the disease. I never saw any
kind of mischief or alarming symptom from this method of extir-
pating this disease, except in one unfavourable subject, who had
been liable to complaints about the neck of his bladder: in him the
operation brought on a return of his old maladies — strangury and
suppression of urine, which induced a necessity of using the ca-
theter for some time; but this subsided, and left him as soon as the
tumors were separated. I do not mention this case as a prohibition
to the operation, but to show that it is right to attend carefully to
the parts contiguous, which are liable to be affected by the neces-
sary inflammation; that if the patient has been subject to complaints
about the bladder, proper care may be taken to obviate and prevent
them. Except this, I know of no harm which ever does, or can
arise, from the operation. Particular care should be taken to
draw the ligature sufficiently tight: if it be at all too slack, some
vessels remaining pervious, the circulation will be continued in
some part, by which the duration of the pain, and the existence of
the tumors, will be protracted. In general, the parts, losing their
nourishment, die and drop off in four or five days. I need not men-
tion that a proper antiphlogistic regimen, both before and after the
operation, should be observed. An anodyne injection, thrown up
the rectum half an hour previous to the operation, will be effi-
cacious in lessening the subsequent uneasiness. A soft poultice
will be found to be the best topical application.

The following cases were obligingly communicated to me by
Mr. Harvey, who attended them with Mr. Pott, and took notes of
them at the time: they will greatly tend to elucidate the nature of
the complaint, and the excellence of the remedy which I have
endeavoured to describe.

ON HEMORRHOIDAL EXCRESCENCES. 409

CASE I.

A gentleman of about fifty years of age, and of a nervous,
irritable constitution, had been during many years of a costive
habit of body, and generally had recourse to aloetic pills to procure
stools. About two years before Mr. Pott saw him, he first per-
ceived a pain and swelling within the rectum, which was very
troublesome whenever he attempted to discharge his faeces; until
at length the difficulty of evacuating them became so great, that he
was obliged to inject oil, and to sit over the steam of warm water, be-
fore he could obtain any natural relief. He was obliged to be very
strict in his diet, as any food which was apt to occasion hardened
faeces most certainly gave him excruciating pain. The frequent
strainings had made a prolapsus of the gut habitual; neither could
he get rid of the faeces, unless the excrescences were first protruded
beyond the anus. In this situation he travelled from Cork to
London, for Mr. Pott's advice. I should have observed, that the
surgeons he had before consulted were led to believe, from the
usual remedies for the piles not having benefited him, and from the
unalterable hardness of the tumors, that they were cancerous.
When I first saw him, he was much weakened by the constant
irritation, and probably by the continual ichorous discharge, which
was so profuse as to wet through many folds of linen in the course
of a few hours. Mr. Pott immediately proposed the operation for
removing them; and in this case, as in the others, he preferred
doing it by ligature, rather than by the knife or scissors: round the
anus there hung a loose flaccid skin, which Mr. Pott supposed had
been a double fold of the inner coat of the gut protruded, and which
had lost its natural texture and colour. The first excrescence
which appeared seemed large enough to have filled the circum-
ference of the intestine: it had a broader basis than I have usually
since seen; therefore Mr. Pott passed a double ligature through;
and tying them on each side, left it to slough off, which it did in a
few days. Afterwards two smaller ones came forward, were

vol. ii. ^ F

410 ON HEMORRHOIDAL EXCRESCENCES.

held by the hook, and surrounded by the ligature: they also came
away in the poultices, and the gentleman returned home, in the
course of three weeks, perfectly cured.

The progress and symptoms of the other cases were nearly the
same; therefore I need not be minute in describing them.

CASE II.

Mrs. had been many years dreadfully afflicted with this

disease, and the surgeons of the town where she resided pro-
nounced it absolutely to be a cancer: her pain prevented her from
walking or sitting upright, and she lay on a sofa, patiently expect-
ing a painful death. Mr. Pott saw her during one of his excur-
sions to Worcester: she followed him to London; and the opera-
tion was performed so successfully, that not only the excrescences
were removed, but her health and spirits, which were before
wretchedly reduced, were again perfectly restored. The excres-
cence in this case was large, rugged, and unequal in its surface :.
it had an ulcerous appearance, and very well authorized the.
opinion which the surgeons in the country had given of it.

CASE III.

A gentleman between thirty and forty came from Carlisle, on
account of this complaint, to Mr. Pott. I have seldom seen a man
more debilitated or nervous: the least surprise made him hysteri-
cal: he had laboured under the disease about a year; and from
his peculiar irritability, it was accompanied with spasms at the
neck of the bladder, pain in the urethra, and a discharge from the
penis, as well as from the rectum, which was also protruded.
Two excrescences were removed; and afterwards two lesser ones,
not having their support, came forward, and were likewise taken
away. This gentleman suffered more pain at, and after the ope-
ration, than in any instance I have seen: he had a small fever,
and a great tendency to strangury. With the exhibition of
anodyne and proper antiphlogistic remedies he recovered; the pro-

UN HEMORRHOIDAL EXCRESCENCES. 411

tYuded intestine returned, the irritation of the neck of the bladder
left him, and he gained a very improved state of health.

The foregoing observations, as has already been stated, ap-
peared in my edition of Mr. Pott's works, published in 1790;
since which a great number of cases, of a similar nature, have been
submitted to my care. The attending progress and symptoms
were so nearly similar to those which have been described, that it
is needless to enter on a minute description of them: yet I cannot
avoid mentioning the case of a young lady, who had the complaint
to a great degree, and who resided at a very considerable distance
from the metropolis. The case was described to me by letter, in
which it was said that the excrescence was very large, and fur-
nished so much blood, at every exertion of going to stool, that her
constitution was impoverished to the most extreme degree. From
the hopes I gave her friends, they were induced to bring her, by
short journeys, in a kind of litter, to London. When she arrived,
she had lost so much blood during the journey, that she was al-
most exhausted: her lips were nearly colourless; and the blood
which continued to be evacuated from the part would scarcely
tinge linen. I do not know that I ever saw a nearer termination
of existence which did not really prove so. To maintain the
small remains of life, Madeira, brandy, and strong broths were
given, and eagerly called for. On examination, the tumor was
about nine inches in circumference, separable into several lobes,
and altogether like a piece of sponge, bleeding from every pore.
It was, however, of a healthy appearance, soft and compressible.
I lost no time in comprising it in a sufficient number of ligatures:
from that moment the bleeding ceased. The next day she found
herself better, her strength improved, she gradually lost the de-
sire for wine and spirits, which before were necessary to keep her
from fainting. By the assistance of the bark, nourishing food,
and proper attention, her constitution, which was naturally good,
soon recovered itself, and in about six weeks she was able to re-
turn home, in good health, which she has now enjoyed several
years. I am informed that her florid complexion is returned, and
that she rides, dances, and partakes of all the diversions which
the country affords.

412 ON HEMORRHOIDAL EXCRESCENCES.

I think this was the most alarming case I ever met with, though
I have seen several nearly as large, and which had reduced the
patients to an extreme degree of debility. After all my expe-
rience, the best advice which I can give, is, that whoever is af-
flicted with this complaint, should apply early for surgical relief:
for, from the time that the protrusion is once established, it be-
comes an increasing evil, which never diminishes, but gradually
grows larger and larger. Now, if it cannot be removed by any
means but an operation, the difficulties attending such operation
must be greater in proportion to the increase of the tumors; con-
sequently it must be more easily performed, and attended with
less pain when the tumors are of small size.

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INDEX.

[The Roman Numerals refer to the Volume, the Figures to the Page.]

Abscesses near the anus, how they all came to be esteemed fistu-
las, Vol. II. 203. See Fistula.

JEgylops, that stage of the fistula lachrymalis described, I. 190.
Serjeant Wiseman's mistaken account of this disease, 194, note.
Dr. Turner's, ibid. note.

Amputation, circumstances in fractured limbs that indicate the ne-
cessity of the operation, I. 265. Not to be deferred in desper-
ate cases on precarious expectations, 266. Some address ne-
cessary to satisfy the patient of the necessity of parting with the
limb, 267. Is the only resource against an approaching gan-
grene, 260. Never avails after a gangrene is commenced,
ibid. Three stages in a bad compound fracture, in which it
may be necessary, 283. Arguments in favour of, when circum-
stances dictate the operation, II. 307. Remarks on Mr. Bil-
guer's tract, written to discountenance the operation, 309.
Cases in which amputation may become necessary, 310. Com-
pound fractures, ibid. A mortified limb, 315. Scrofulous
joints, ibid. Mr. Bilguer's recommendation of amputating at
the hip joint, rather than in the thigh, considered, 317, note.
General characteristics of an aneurism, 318. The common
operation for, ineffectual, 319. Amputation the only known
method of cure, 320. Objection to, ibid, note, E. AJeg disorder-
ed by a bursten artery, 321. The patient only to be saved by
amputation, 322. Caries of the bones forming a limb, requires
amputation, ibid.

Anatomy, the knowledge of, a principal cause of the improvement?
in surgery, I. 301.

And. M. account of the instruments he employed in the fistula
lachrymalis, I. 196.

Aneurism, general characteristic marks of, II. 318. The com-

VOL. II. 3 G

414 INDEX.

mon operation for, ineffectual, 319. Amputation the only
known method of cure, 320. Objection to, ibid, note, E. See
Leg.
Anus, case from the Memoirs of the French Academy, where the
whole was extirpated for a fistula, II. 238, note. See Fistula.

Bandages for a wounded head, remarks on, I. 143. For a frac-
tured limb, 229. For an irreducible omental rupture, I. 339.

Bark, Peruvian, its great power of resisting gangrenes and morti-
fications, II. 297. Excepting when beginning in the toes, 299.
Instances of its proving successful combined with opium, ibid.

Bed, newly invented, for patients with a fractured thigh, and
other cases, I. 258, 284, note, E.

Belly, the external oblique muscle of, the only one which has any
opening in it, I. 308, 390, note, E.

Bertapal, his opinion in favour of trepanning, for fractures in the
cranium, I. 105, note.

Bilguer, Mr. remarks on his tract against the practice of amputa-
tion, II. 309.

Bladder, spasmodic affections of, attending abscesses near the rec-
tum, how to be treated, II. 211. See Hernia vesical urinaria^.

Blood, extravasated, does not turn to pus, I. 47.

Bone, rising end of a broken one, the common notion of, and the
means used to guard against it, examined, I. 252. Rendered
soft by tumors, II. 387.

Bone-setting, the art of, professed by the most ignorant of men
and women, I. 217. Examination of a judicial opinion in this
case, 218.

Brain, symptoms of its being affected by wounds that pierce, I.
39. Signs of a commotion of, from a smart blow on the head,
55. See Cases. Wounds of, how to be treated, 142. Extra-
vasation of the circulating fluid, and commotion of the sub-
stance, symptoms of, 148. Loss of sense by commotion, and
by extravasation, distinguished, 150. General treatment of,
152. Circumstances which require a division of the dura
mater, 156. Symptoms of a concussion, 160. Different de-
grees of, ibid. The only method of treatment, 162. Stages
of the cure, ibid. Appearances that destroy the hope of cure >
ibid.

Breast, remarks on the removal of, II. 149, ibid, note, E.

Bubo, venereal, its distinction from a true hernia, I. 312.

Bubonocele. See Rupture.

Callus of the bones, the nature of, explained, I. 233. The
causes of its producing deformity, ibid.

INDEX. 415

Cancers, character of the solanum as a medicine for, II. 65. Are
deemed incurable, II. 255.

Cancer scroti, a disorder peculiar to chimney-sweepers, II. 291,
note, E. Danger of treating it as a venereal complaint, ibid.
The distempered part to be removed, 292.

Cancer quackery, the artifices of, exposed, II. 133, ibid. note.

Caries, of the cranium, often produced in old or neglected stages
of venereal disorders, I. 85. This species of caries incurable,
86. Of the bones forming a limb, only to be cured by ampu-
tation, II. 322. Of the joints, caustics recommended in, 383,
note, E.

Caruncule of the eye, not the organ that secretes the tears, I. 179.

Cases, of a considerable portion of the scalp preserved, I. 34,
note, E. Of contusions of the head, 63. Of the exfoliation
of both tables of the cranium, from external violence, 89. Of
simple fractures, 121. Of depressed fractures, 144. Of ex-
travasations in the brain, 164. Of fractures of the inner table
of the scull only. 170, 171. Of compound fracture, 273, note,
E. Of a gangrene of the omentum in an old rupture, I. 331.
Of omental ruptures. 394. Of intestinal ruptures, 412. Of
congenial ruptures, 419. Of inflammatory and other com-
plaints attending, but independent of, the ruptures, 424. Of her-
nia? vesica? urinaria?, 433, II. 397. Of an ovarian hernia, I.
' 436. Of hydroceles, II. 26, 34. Of the hydrocele in the tuni-
ca communis, 46. Of the encysted hydrocele of the tunica
communis, 47. Of a hydrocele of the tunica vaginalis testis,
60, 68, 72. Of a haematocele, 99. Of a hydrocele formed in
the sac of a true hernia, 110. Of a circocele, 115. Of scir-
rhous testicles, 151. Of the palsy in the lower limbs, 337.
Of a scrofulous joint, 382, note, E. Of tumors rendering the
bones soft, 389.

Castration, when performed in time on a proper subject, not a
dangerous operation, II. 132. But no cure when a testicle is
become cancerous, ibid. Caution against delays in scirrhous
cases, 137. Circumstances which prohibit the attempt, ibid.
The state of the spermatic chord, the principal object of consi-
deration, 139. Method of performing the operation, 144.

Cataplasms, why injurious to a strangulated hernia, I. 336. Re-
cipe for a neat one, 88, note.

Cataract, the nature of this disorder not understood fifty years ago,
II. 265. Is a distemper of the corpus crystallinum, ibid. What
is generally understood by its progress from immaturity to ripe-
ness, 266. Danger of attending to this opinion, ibid. The
consistence of the crystalline described, 267. From what the
ancient distinctions in this disorder arose, ibid. note. The mere
colour of a cataract furnishes no proof to judge of its consistence,

416 INDEX.

270. Objections to the operation of couching considered, 271.
The capsuie of the crystalline often found to have an unsuspected
share in a cataract, 274, note. Cataract cured by the needle
without depression, 275. Will dissolve when detached from
its natural nidus, 278. '

Cathartics, inquiry into the utility of, in strangulated hernias, I.
337, 409.

Caustic, ancient method of curing ruptures by, 1. 384. Objec-
tions to it as a radical cure for the hydrocele of the tunica
vaginalis testis, II. 82. Improper for making openings for the
fistula in ano, 215.

Cautery, ancient mode of curing ruptures by, I. 384.

Cellular membrane, capable of being rendered firm and compact
by constant pressure, I. 328.

Celsus, his reason against trepanning a fractured cranium, I. 105,
note. His account of the use of the ligature to unite the opening
of an abscess to that of the rectum, in the fistula in ano, II. 227,
note.

Cerate, composition of that used at St. Bartholomew's hospital, I.
228.

Cheselden, Mr. his recommendation of the cautery for perforating
the os unguis, examined, I. 210. His description of the muscles
of the belly erroneous, I. 307, note. His notion of the hernial sac
corrected, 310. His account of the hydrocele, and the cure of it,
erroneous, II. 9, note. Remarks, on his method of treating the
fistula in ano, 229.

Chimney-sweepers peculiarly liable to a cancer in the scrotum, II.
291. The singular hardships of this class of people, 292. See
Cancer scroti.

Cicuta, general opinion of its effects in scirrhous and cancerous
cases, II. 157.

Circocele, description of that disorder, II. 114. Cases of, 115.

Clavicle, broken, and erroneous treatment of, pointed out, I. 253.

Clysters, stimulating, their efficacy in obstinate ruptures, I. 338,
411.

Cceeum, or the beginning of the colon, a portion of, being contained
in the hernial sac, frequently prevents the reduction of ruptures,
I. 327.

Concussion of the brain. See Brain.

Contrafissures of the cranium, the ancient idea of examined, I. 115.

Contusions of the scalp, symptoms of. I. 42. Danger of mistaking
the tumor produced, for a fracture, ibid. On the dura mater,
44. Separation of the tables of the cranium by, 85. Cases,
63,89. J

Coi'tesius, an advocate for perforating the sutures of the head, when
dictated by circumstances, I. 141.

INDEX. 417

Couching for the cataract, objections to the operation considered,
11.271. Experiments, 276.

Cranium, the separation of a portion of both tables of, not unfrequent
in old venereal disorders, I. 85. Cases of exfoliation of both
tables of the cranium from external violence, 89. Fissures and
fractures of, without depression, 94. The symptoms of, defined,
95. Why trepanning is needful in fractures, 97. Ancient
mode of treating fractures of, 106. Defects of the ancient chi-
rurgical instruments used in perforations, and removing portions
of bone, 107. Diagnostic signs of a fractured cranium,
fallacious, 112. Conclusions from the circumstances of the
injury equally uncertain, 1 13. Proper mode of discovery, ibid.
Treatment, ibid. Injuries in or under the frontal bone, supposed
to be easier curea than in any other, 127. Reasons why they
are, ibid, note, E. The sutures of, no obstruction to the exten-
sion of a fracture from one bone to the other, 131. Fractures
of, with depression, 135. How treated by the ancients, 136.
Modern method, 137. Usual consequences of such a depression,
ibid. Circumstances which dictate a removal of the depressed
portion, 139.

Crystalline of the eye, the consistence of, described, II. 267. The
opacity of, no proof of induration, 268.

De la Faye, Mr. remarks on his operation for the fistula in ano,
II. 230. And on his instructions for the blind internal fistula.
248.

Definitions, clear and precise, the importance of, in surgery, II.
203.

Diagnostic signs of a fractured cranium, the fallaciousness of, I.
94, 112.

Dionis, his definition of the true fistula in ano, II. 250.

Diseases, the proper application of names to them, of great con-
sequence in the art of surgery, II. 203.

Dislocations, the reduction of them by the ancient surgeons, prin-
cipally attempted by violence, I. 287. Knowledge and dexterity
more successful than force, 288. The resistance of the muscles
the chief objects of attention, ibid. Leading principles relating
to luxations in general, 289. Errors in the popular methods of
reduction pointed out, 292. The necessary force in reduction,
to be applied gradually, 295. Best mode of extension in, ibid.

note, E. .

Dura mater, its intimate attachment to the inside ot the scull, and
free communication by vessels with other parts, I. 44. How
affected by external injuries, 45. Complaints produced by
extravasation, 47. Symptoms attending an inflamed state of
the membranes, ibid. The matter found on its surface not made

418 INDEX.

from extravasated blood, 48. Opinion of French writers on
contusions of the head controverted, ibid. Inflammatory effects
of contusion, 49. Progress of the disorder, ibid. Contusions
with a wounded scalp, 52. Consequences of the blow being
near a suture, in a young subject, 53. Contusions that claim
an early regard, the least dangerous, 54. Erroneous opinions of
its pulsatory motion, 57. Ill effects of this error in the treatment
of contusions, 58. Importance of preventing the inflammation
of, 59. Discharge of matter collected under the cranium, how
to be effected, 60. How to be treated, when laid bare by a per-
foration of the scull, 62. Cases, 63. How.to form a judgment
of the state of the dura mater, before a perforation of the cra-
nium, 118. Must be laid bare to the extent of the depression,
139. The detachment of the pericranium from the scull with-
out, generally attended by a detachment of the dura mater within,
156. A division of, sometimes necessary, 157. Signs that
indicate the necessity of opening it, 159.

Else, Mr. an advocate for caustics in the cure of the hydrocele,
II. 179. Reply to, 187.

Embrocations, why injurious to a strangulated hernia, I. 336.

Enterocele. See Rupture.

Epididymis, description and use of this body, II. 129. How af-
fected in venereal cases, 130. Requires no manual operation
in any, ibid. A schirrus seldom commences in this part, ibid.

Epiplocele. See Rupture.

Erysipelas, persons affected with, unable to bear much evacua-
tion, II. 209.

Exfoliation from a cranium laid bare by external violence, as
often produced by art as by nature, I. 38. Causes of,
58. note.

Extravasation. See Brain and Dura Mater.

Eye, the origin of the lymph that moistens it, explained, I. 182.
Its external organs described, ibid. Consistence of the crys-
talline explained, II. 267. See Cataract.

Fabritius ab Jlquapendente, account of the instrument employed
by him in the fistula lachrymalis, I. 197. His notion of perfo-
rating the os unguis, 207, note. His instructions for bandag-
ing a fractured limb, 229, note. True nature of the disorder
called by him the hydrosarcocele, II. 122. His mode of cure,
124. Remarks on, 180, 181.

Faget, Mr. case related by him, where the whole extremity of
the intestine was extirpated for a fistula in ano, II. 238, note.

Fallopius, his account of the indications of a contused head, I.
49, note. His account of the hydrocele in the tunica commu-
nis, and in the tunica vaginalis testis, II. 51, note.

INDEX. 419

Fibula, consequences of its fracture, I. 247. Difficulties of setting
it, with the limb in an extended position,r249. Easy reduc-
tion of it, when the muscles are in a state of relaxation, ibid.
Fissures in the cranium, how distinguished from fractures, I. 95.

Contrafissures, the ancient idea of, 116.
Fistula, ancient idea of, II. 203. Their rash treatment of dis-
orders included under this name, 205. In ano, its various
symptoms, ibid. Often extends its influence to the neighbour-
ing parts, 206. Sometimes proceeds from the lues venerea, or
cancerous complaints, and therefore requires a treatment adapt-
ed to the case, 208. If from an erysipelatous inflammation,
large evacuations improper, 209. Spasmodic affections of the
neck of the bladder, how to be treated, 211. A tenesmus, how
relieved, 213. Costiveness, ibid. The due treatment of these
accessory complaints, of great importance to the original dis-
ease, ibid. The circumstances of the disorder, when the col-
lected matter is ripe for discharge, reduced to two general
heads, 214. Caustics improper to make openings for a dis-
charge, ibid. How to make the opening with a lancet, 215.
The general method of dressing, wrong, 217. The process of
nature in such a case considered, 218. When the intestine re-
quires opening into the abscess, 219. Fanciful instruments for
this purpose condemned, 220. Proper dressing, 221. State
of the abscess when the collected matter has burst its own way
out, 225. Ancient modes of cure in this case, 226. The
proper method of uniting the opening of the abscess into the
rectum, by incision, 227. Remarks on Mr. Cheselden's me-
thod, 228. Remarks on Mr. De la Faye's operation, 230.
Incision sufficient without excision of substance, 233. Re-
marks on Mr. Le Dran's method of operation, 234. The only
dressing necessary on incision, 236. If the wound assume an
unfavourable appearance, the remedy must be internal, ibid.
Inconsistency in Mr. Le Dran's methods pointed out, 238. In-
conveniences produced by excision, 241. State of the case
when several natural openings have been made, 244. These
separate orifices generally all from one abscess, ibid. Proper
treatment of them, 245. Distinct sinuses very uncommon, 246.
The blind internal fistula described, 247. An external open-
ing to be made in this case, ibid, Definition of the true fistu-
la in ano, 250. Two classes of, ibid. The origin of the dis-
order to be first attended to, ibid. The necessary chirurgical
operation that should follow, 252. Fungous flesh, how to be
reduced ibid. Unfavourable circumstances from injudicious
treatment, how to be removed, 253. Abscesses about the lum-
bal vertebrae require medicinal care, 254. Cancerous sores
in the neighbourhood of the rectum deemed incurable, 255,

420 INDEX.

Fistula lachrymalis, the cause and seat of this disorder erroneous-
ly represented by ancient writers, I. 179. Their methods of
treating it, 180. Its true seat ascertained, and the modern in-
tentions of cure explained, 181. On what circumstances its
various appearances depend, 184. Symptoms, 185. Not so
often attended with an ulcer or abscess in the duct, as is ima-
gined, 186. The purulent colour of the mucus, no necessary
sign of an ulcer, ibid. That stage of the disorder termed the
perfect Eegylops, described, 1 90. A carious state of the bones,
191. The producing causes of this disorder, 192. Different
stages of the disorder described, 193. Consequences of endea-
vouring a suppuration of the supposed abscess, 195. Account
of the instruments M. Anel employed in this disease, 196.
Account of that used by Fabritius ab Aquapendente, 197.
Methods of treatment used by the French academy, 198.
Proper treatment in the inflamed state, 199. The destruc-
tion of the cyst to be guarded against, 202. This sometimes
effected without intention, 203. Escharotic dressings there-
fore to be avoided, ibid. Proper applications, 204. Great
uncertainty in these cases, 205. When, and how an artifi-
cial passage is to be made for the lachrymal fluid, 206. Ought
not to be performed by cautery, 209. The best instrument
for this purpose, 211. How to prevent the incarnation from
closing the orifice, 213.

Fomentations, warm, why injurious to a strangulated hernia, 1. 336.

Fractures, the general doctrine of, how distinguished, I. 219. The
practice capable of considerable improvements, 220. Remarks
on the extension of fractured limbs, 221. Why putting the
muscles in a state of tension is improper, 224. Why the os
humeri is easier set than the os femoris, 225. The proper
conduct in the latter case, 226. The adhesive plaster, wfiy
an improper application, 228. Composition of the cerate
used at St. Bartholomew's hospital, ibid. The broken limb
not to be moved until the fracture is united, ibid. Bandages,
ibid. Strong objections against the use of rollers, 230. The
eighteen-tailed bandage; the best for simple fractures, 235.
The disadvantages attending splints, 236. Proper positions
for a fractured limb, 239, 241, note, E. Fractures of the tibia
and fibula, 247. Two kinds of, which do not admit of being
reduced with a bent joint, 249.

Fracture, compound, the term explained, I. 265. Circumstances
that indicate the necessity of amputation, ibid. Mode of pro-
ceeding in attempts to preserve the limb, 267. In protrusions
of the bone, ibid. Applying the saw to the protruded bone fre-
quently a wrong conduct, 268. How to reduce the bone, ibid.
Detached bones to be removed, 269. The great objects of ap-

INDEX. 421

prehension in compound fractures, ibid. Necessary dressings,
271. Cataplasms unnecessary without the limb is tumid and
painful, 272. Danger of admitting air to, 273, note, E. An-
tiphlogistic regimen to be rigidly adhere to at first, 276. The
three general events of a compound fracture, and proper treat-
ment in each, ibid. How to proceed on inordinate discharges
of matter, 279. Gangrenes and mortifications, how they ori-
ginate, 280. If likely to take place, recourse must be had to
immediate amputation, 281. But not after a gangrene has
begun, ibid. Three points of time at which the operation of
amputation may become necessary, II. 310.
Fractures, of the cranium, undepressed, general consequences of,
to the dura mater, I. 54, 98. The symptoms of, defined, 95 k
Why trepanning is requisite in such cases, 97. Ancient me-
thod of treating, 106. Defects in the ancient chirurgical instru-
ments for this purpose, 107. Fallacious experiments indicating
fractures, 113. Conclusions from the circumstances of the injury,
equally uncertain, ibid. Proper means of discovery, ibid. Best
method of scalping, 114. How to distinguish a fracture from a
suture, ibid. The ancient doctrine of contrafissures, fallacious,
115. Cases of simple fractures, 121. The course of, not inter-
rupted by the sutures of the cranium, 131. Fractures of the cra-
nium with depression, 135. How treated by the ancients, 136.
Modern method, 137. Circumstances which dictate a removal
of the depressed portion of bone, 139. Cases of fractures of the
inner table of the scull only, 170, 171.
Freke, Mr. the instrument he called his commander, why a bet-
ter instrument in reducing luxations, than the common ambi, I.
293. His instrument for dividing the rectum in the fistula in
ano, condemned, II. 220, note-
Galen, his account of the use of the scalpra in fractures of the

cranium, I. 106, note.
Gangrenes and mortification, in compound fractures, how they
originate, I. 280. If likely to take place, recourse must be im-
mediately had to amputation, ibid. Amputation of no avail,
when once begun, 281 . But nature may sometimes be assisted
in separating the diseased part from the sound, ibid. Pro-
per remedies while a gangrene is forming, ibid. Scarification
of no service, 282. The uncertain time of apprehending gan-
grene in an incarcerated rupture, 342. The operator to an-
ticipate a gangrene, not to wait for it, 344. How to treat the
omentum, if in an unsound state, 359. How to treat the in-
testine if affected, 362. Sphacelated spots on the surface of an
intestine no absolute prohibition against returning it, 431. Effi-

VOL. II. «* H

422 INDEX.

cacy of the Peruvian bark in gangrenes and mortifications, II.

299. See Toes.
Glandula lachrymalis, its office explained, I. 182.
Gonorrhoea, the discharge from, not pus, I. 188.
Gunshot icounds, the notion of their being of a poisonous nature

from the fire, erroneous, I. 282. Are to be treated as contused

and lacerated wounds, ibid.

Hcematocele, the different kinds of that disorder, II. 94. Origin
of, ibid. Castration not necessary in this complaint, 96. The
appearances, if mistaken and treated as a simple hydrocele, 98.
Cases of, 99.

Heister, his accounts of the incysted hydrocele of the tunica com-
munis, II. 42, note. Remarks on his directions for the cure of
the simple hydrocele by incision, 56, note. Remarks on his
directions for treating the fistula in ano, 239, note.

Hernia, congenial, how formed, I. 372. Commences in infancy,
374. The application of a truss, when improper in, ibid. Ad-
hesion of the parts more frequent in this, than in the common
rupture, 375. Circumstances necessary for the practitioner's
consideration, 418. Cases, 419. Cases of, combined with a
hydrocele, II. 110.

Hernia cystica, described, I. 380. See Hernia vesicce urinaria:.

Hernia, female, described, I. 367. The hernial sac to be opened
with more caution than in men, 368. Why is it so often fatal,
ibid. Symptoms of a strangulated rupture, 369.

Hernia, femoral, the structure of the parts where it is formed, de-
scribed, I. 370. Method of performing the chirurgical opera-
tion for, 371. Necessary cautions in the operation, ibid.

Hernia foraniinis ovalis, 380, note, E.

Hernia humoralis, its distinction from a scrotal hernia, I. 313.

Hernia, incarcerated, symptoms of, I. 341. Difficulty of deter-
mining the precise time for using the knife, 343. The nature
of the operation considered, ibid. Critical time for attempting
it, 344. A gangrene is to be anticipated, not waited for, ibid.
Method of performing the operation, 346. Whether the dis-
order be originally in the intestine or not, inquiry into, 415.
The symptoms of, to be carefully distinguished from those pro-
duced bv inflammation, or spasmodic affections of the same part,
423.

Hernia, intestinal, symptoms of, I. 408. The reduction of the
intestine, how to be attempted, ibid. The propriety of cathartic
medicines inquired into, 337, 409. Stimulating medicines
given per ano more efficacious and less dangerous, 411. Cases.
412.

Hernia, ovarian, case of, I. 436.

INDEX. 423

Hernia, scrotal, its origin, I. 309. Nature of the hernial sac ex-
plained, ibid. Signs of this disorder, 311. Signs of the omen-
tal kind of hernia, 312. If both intestinal and omental, ibid.
How to be distinguished from the venereal bubo, the hydro-
cele, and hernia humoralis, ibid. The testicle not to be felt in
old ruptures, 313, note. The intestine most usually found in a
scrotal hernia, ibid. Various appearances of the disorder un-
der different circumstances, 314. Not often attended with hazard
in infants, ibid. The principal danger to be apprehended in
adult patients, 315. General rules for the treatment of this dis-
order, ibid. When a reduction had better be unattempted, ibid.
Usual consequences of a sudden hernia, from effort or violence,
316. An old omental hernia, how often rendered irreducible,
ibid. Strangulation of the gut in an intestinal rupture, 317.
An intestinal rupture more hazardous than an omental, 318.
Origin and progress of the disorder, 321.

Hernia, spurious, distinguished from the true rupture, II. 5. The
several species of, 6.

Hernia, ventral, what, I. 380.

Hernia vesica} urinaria}, described, I. 380, 433. Cases of, ibid.
Case of one including a stone, I. 381, II. 395.

Hernial sac, the nature of explained, I. 309. Never returns into
the belly of adult patients, 310. The coecum or the beginning
of the colon being contained in it, renders ruptures difficult to
be reduced, 327. How to apply the knife to it, in incarcerat-
ed ruptures, 346.

Hildanus, his account of the hydrocele, II. 8, note.

Hydrocele, its distinction from a scrotal hernia, I. 312. Descrip-
tion of the disorder, II. 7. Erroneous opinions as to the collec-
tions formed in the vessels, ibid. Bad effects of these mistakes
on practice, 10. Description of the spermatic vessels, 11.
Description of the testes, 14. Origin of the disorder traced,
16. Cases of, 18. Anasarcous tumor of the scrotum, 23. Of
the hydrocele in the cells of the tunica communis, 31. Cases
of, 34. The encysted hydrocele of the tunica communis, 42.
Cases of, 46. Of the tunica vaginalis testis, 51. Palliative
method of cure, 69. Means for a radical cure, 77. Objec-
tions to the cure by incision, 92, note, E. The haematocele,
94. A hydrocele formed in the sac of a true hernia, 1 10. Me-
thod of distinguishing this disorder from the intestinal hernia,
or common rupture, 176. Review of the several methods prac-
tised for its cure, 177, 189. Instruments made use of in the
application of the seton, 185. Cure of, by injection, 193, k.

Hydrosarcocele, description of that disorder, II. 122.

Incarcerated hernia, the nature and symptoms of, explained, I.
333. See Hernia.

424 INDEX.

Induration, remarks on those applications termed dissolvers of,
II. 88, note.

Inflammation of membranous parts, the utility of phlebotomy in
preventing, I. 59, 124.

Injections, advantages of, in certain cases, II. 194, E.

Instruments, ancient, for perforating the cranium, their imperfec-
tions considered, I. 107. Reduction of the number of, great
part of the merit of modern surgery, 111. Their handles to be
made as light as possible, l\2, note.

Lachrymal gland, its office explained, 1. 182.

Le Dran, quotations from, concerning external injuries to the head,
I. 46, 54, 56, 62, 96. His .distinction between the loss of
sense by commotion of the brain, and by extravasation of the
fluid in, 150. His case of a returned rupture, which killed the
patient by the stricture of the neck of the sac, over a portion
of the gut in the abdomen, 365. His description of the hydro-
cele of the cells of the tunica communis, II. 32, note. And of
that in the tunica vaginalis testis, 54, note. Objections to his
method of castration, 146. Remarks on his operation for the
fistula in ano, 234. Absurdity in, pointed out, 238.

Leg, description of a dangerous disorder produced by, or attended
with, a bursten artery, II. 321. Amputation the only known
method of saving the patient, 322.

Ligaments of the joints, their nature and use, I. 289. Laceration
of, in dislocations, not dangerous, 290.

Ligature, absurdity of using it to open the intestine into the ab-
scess, in a fistula in ano, II. 227.

Lues venerea. See Cranium.

Luxation. See Dislocation.

JMapp, Mrs. her extraordinary reputation and character, I. 217.

Meekren, his correction of Fabritius ab Aquapendente in his de-
scription of the hydrocele, II. 126, note.

Mercury, destructive to the human constitution, I. 87.

Monro, Dr. of Edinburgh, account of his method of reducing
strangulated hernias, I. 337, note. His hints for a radical cure
of the hydrocele in the tunica vaginalis testis, II. 80, note.
Remarks on, 182.

Morgagni, his idea of what are called contrafissures in the crani-
um, I. 116, note. His objections to perforation on extravasa-
tion of fluids within, examined, 154.

Mucus of the eye, and other glandulous parts often of a purulent
colour, without proceeding from ulceration, I. 186. Distin-
guished from pus, 187.

Muscles, ought not to be put in a state of tension to set a fractuf-

INDEX.

425

ed limb, I. 224. Nor in dislocations, 287. Of the belly de-
scribed, 30G.

Obliquus descendens, the direction of the tendon of this muscle de-
scribed, I. 348. The operation on it in incarcerated hernias,
349. The stricture by this tendon, the general cause of stran-
gulated ruptures, ibid. An attention to this circumstance of
importance to the operator, 350. The structure of the muscle
described, 370.
Ointment, character of an operose one, recommended for reducing

strangulated intestines in a hernia, I. 337.
Omental ruptures, caution against the neglect of, I. 339. How
to treat irreducible cases, ibid. Proper bandage for, 340.
The chirurgical operation ought not to be performed for the
cure of, 355, note. The general doctrine of them examined,
391. The primary and secondary evils attending them, ibid.
The use of trusses and bandages to young subjects, 393. Cases
which discourage the use of the ligature previous to extirpation,
404.
Omentum, that part of it compressed in the neck of a hernial sac,
formed into a hard carnous body, taking the figure of the pass-
age, I. 328. Case of a gangrene of, 331 . How to be treated
in the operation, if found to be in a gangrenous state, 359. Ob-
jections to taking it away by ligature, 361. The safest method
of taking it away, 362.
Opium, when joined with purgatives, is successful in intestinal
ruptures, I. 410, note. Its efficacy in retentions of urine of a
spasmodic nature, II. 211, note. Successful instances of its
stopping a mortification in the toes, 299.
Oribasius, his account of the ancient method of taking away por-
tions of a fractured cranium by terebrae, I. 109, note. His
remarks on bandages for the head, 143, note. His signs of re-
covery or death in wounds of the brain, 163, note. His observa-
tions on splints for fractured limbs, 237, note.
Os femoris, fractured, a capital error in the mode of setting it,
pointed out, I. 225. The proper conduct on such an occasion,
226. Due position of the limb, 241.
Os humeri, fractured, why easier set than other bones, I. 225.
Os unguis, when a perforation of this bone is necessary in the nslula
lachrvmalis, I. 206. Ought not to be performed by cautery,
209/ Examination of Mr. Cheselden's opinion on this point,
210. The best instrument for the operation, 211.
Oscheocele. See Rupture.

Palsy of the lower limbs, description of .the ■ disorder «L 3 3L
Symptoms of it in infants, ifod. In adults, 332. Distinction

426 INDEX. ,

of this disorder from a common nervous palsy, ibid. The curva-
ture of the spine that accompanies it, described, ibid. Progress
of the disorder, 333. Considerations drawn from observation,
335. Circumstances observed by examination after death, 336.
Hint derived from Hippocrates, of its cure by an abscess in the
loins, 337. Cases of its cure by procuring similar discharges,
ibid. Method of operation, 339. Inferences as to the nature
of the disorder, 348. See Useless state of the lower Limbs.

Patella, the fracture of, requires a straight position of the leg, on

the same principle that other fractures require a bent position

of the limb, I. 249. Inquiry into the cause of the rigidity of

the joint that sometimes ensues, 250. Remarks on, 251,

1 note, E.

Pericranium, the spontaneous detachment of from the scull, in con-
sequence of a blow, a positive indication for the operation of
trepanning, I. 156.

Peritoneum, that membrane of the belly described, I. 308. The
hernial sac, what, 310.

Phlebotomy, its importance in preventing inflammations in mem-
branous parts, I. 59, 124. Its utility in the reduction of rup-
tures, 336.

Phlegmon, in the ancient surgery, the term explained, II. 206.

Phyma, in the ancient surgery, what, II. 206.

Pillows, objections to the use of, in/ractured limbs, I. 241, note, E.

Plaster, adhesive, why improper for a fractured limb, I. 228.

Pneumatocele, or windy rupture, no such disorder in a living body,
II. 6,114.

Polypus of the nose, the nature of that disorder considered, II.
283. Not always an object of chirurgical treatment, 284.
Marks of those which ought to be left unattempted, 285. Marks
of those fit for extraction, ibid. Two kinds of those fit for ex-
traction distinguished, 286. Practical inferences respecting
them, 287. Haemorrhages seldom to be apprehended from the
operation, ibid. Attempts for destroying them by escharotics
and medicated setons, condemned, 288. Objections to intro-
ducing the instrument through the mouth for polypi falling back-
wark, 289. Cautions to young practitioners, 290.

Puncta lachrymalia, their office explained, I. 183.

Punctum aureum, account of the ancient method of curing ruptures
by, I. 386.

Puncture, wounds of the head by, their different degrees and
methods of cure, I. 39. In chirurgical operations safer than
incisions in membranous parts, II. 25.

Pus and mucus, too often confounded with each other, I. 186.
Distinguished, 187.

INDEX. 4 2"(

Quackery in surgery, the prevalence of, exposed, I. 217. II. 134,
note. The general policy of the professors, 223. Their success,
the work of nature, 224.

Read y Sir William, his remarks on the operation of couching for
the cataract, II. 275, note.

Regimen, antiphlogistic, to be rigidly adhered to at first, in com-
pound fractures, I. 276.

Richtcr, his account of the operation of extracting the crystalline
humour for a cataract, II. 276, note.

Rollers, arguments against the application of them to fractured
limbs, I. 230, 275.

Royal stitch, account of the ancient method of curing ruptures by,
I. 386.

Rupture, sometime a dangerous disorder, but generally the cause
of groundless apprehensions, I. 299. And hence expose the
patients to the depredations of quacks, ibid. If taken in time
not a profitable disorder to the surgeon, 300. The term defined,
305. The different species of the disoider distinguished, 306.
The scrotal hernia, how occasioned, ibid. The external oblique
muscle of the belly, the only one which has any opening in it,
307, note. The peritoneum described, 308. The tunica vagi-
nalis testis described, ibid. Origin of the scrotal hernia, 309.
The hernial sac described, 310. See Hernia. The cure of
ruptures either palliative or perfect, 318. Disingenuity of pa-
tients, 319. The perfect cure depends on nature, 320. The
futility of pretended specific remedies exposed, 321. General
conclusions, 322. Four classes of circumstances distinguished,
324. The neglect of in proper time, the foundation of future
mischief, ibid. Steel trusses capable of being worn by all ages,
ibid. Cautions respecting the use of them, 325. The little
inconvenience, sometimes attending old ruptures, occasions a
dangerous carelessness in the patient, 326. Irreducible rup-
tures, 327. A portion of the coecum or colon being contained
in the sac prevents reduction, ibid. Induration of the sac, or of
its contents, 328. Adhesion of the parts, 329. Cautions to
the patients, 330. The quiet state of a hernia, no security for
its safety, ibid. Examination of an old irreducible hernia after
death, ibid. note. Reasons why the reduction of a rupture,
deemed incurable, ought to be judiciously attempted, 331.
Ruptures of difficut and hazardous reduction, 333. Symptoms
of 334. How to take off the stricture of the passage, ibid. The
reduction how to be attempted, 335. Efficacy of bleeding in, 336.
Fomentations and cataplasms rather hurtful that advantageous,
ibid. Inquiry into the merit of cathartics, 337. Tobacco clysters,
338. Punctures of the gut through the tumid scrotum condemned.

428 INDEX.

ibid. Circumstances attending strictures, ibid. Caution against
the neglect of omental ruptures, 339. Ruptures that call for
chirurgical operation, 341 . Dangers of strangulation, ibid. Symp-
toms of an incarcerated hernia, ibid. Difficulty of determining
the precise time for using the knife, 343. The nature of the
operation considered, ibid. The critical time for performing
it, 344. A gangrene is to be anticipated, not waited for, 345.
Method of performing the operation, 346, 355. The stran-
gulated hernia not an original disorder in the gut, 349, but
from the stricture of the tendon, ibid. Symptoms of a sudden
rupture that confirm this opinion, 351. Appearance of the
parts after opening, 355. Cautions in the reduction, ibid.
Crural rupture, what, 370. Nature of the congenial hernia,
372. Exomphalos, 376. Ventral and other herniae, 380. At-
tempts towards a radical cure, 382. The several methods re-
commended by the old surgeons, 383. Further observations
and cases, 391. True and false hernias distingusihed, II. 5.

For the several species of ruptures, see under Hernia, Omentum,
and the following article.

Rupture, umbilical, what, I. 376. Its peculiar inconvenience to
women, 377. Methods of cure by ligature, 378. Cure by
bandage in young subjects, ibid. The operation by the knife
very hazardous, 379.

Rupture doctors, their proper reward sometimes mistaken, I. 329,
note.

Ruysch, a follower of Fabritius ab Aquapendente in his method of
treating the hydrocele, II. 181.

Saccuius, lachrymalis, its office explained, I. 183. Is the seat of
the disorder termed fistula lachrymalis, which see, 184.

Sarcocele, the venereal, how to be treated, II. 59. Distinctions
in this disorder among the ancient surgeons, 117. Description
of, 118. Various appearances of, 119. Errors in the theory
of the disorder pointed out, 120. Signs of a scirrhous testicle,
122. Distinctions between a scirrhous testicle and a simple
hydrocele, ibid. The hydrosarcocele, 123. Methods of cure,
131. Castration, when performed in time upon a proper sub-
ject, not a dangerous operation, 132.

Scalp, its various parts specified, I. 31. The injuries to which it
is liable, 32. Lacerated wounds in, ibid. Detached portions
of the scalp, whether to be removed or preserved, ibid. Reasons
for endeavouring their preservation, 33. Circumstances to be
considered in this case, 34. When a suture may be properly
used, 36. Caution respecting the attempt of reuniting the
separated parts, 37. Consequences when a perfect union does
not take place, ibid. Proper treatment in such cases, ibid.
Exfoliation as often produced by art as by nature, 38. When

INDEX. 429

the re-union of detached parts of the scalp is not to be attempted,
ibid. Wounds by puncture, 39. Symptoms of the cellular
membrane only being affected, ibid. Method of cure, ibid. Re-
marks on, 41 note, E. Symptoms of the brain and its membranes
being affected, 40. Method of cure, 41 Contusions, 42.
Danger of mistaking the tumor produced for a fracture, ibid.
Four kinds of tumor incident to the scalp from wounds or bruises,
43. See Cases.

Scalping, in fractures, the proper method of performing, I. 114.

Scarification, of no service in stopping a tendency to mortification,

I. 282. Is an indefinite term, II. 25.

Schenkius, his account of the hydrocele, II. 8, note. His account

of a mistaken sarcocele cured by castration, 123, note.
Scissors, general objection to the use of, in chirurgical operations,

II. 220.

Scrofulous joints, hint proposed for the treatment of, II. 342, 338,
note, E. Case of, ibid, note, E. Description and progress of
the disorder, 316. Amputation when necessary, 317.

Scrotal hernia. See hernia

Scrotum and its parts described, II. 23. Anasarcous tumor of,
ibid. The watery swelling of, not derived from the cavity of
the belly, ibid. Short account of this disorder, 24. Two me-
thods of discharge in use, 25. Cases in which the whole scrotum
was cast off by gangrene, 26. The watery swelling in, con-
sidered under three distinctions, 31. See Cancer scroti.

Seton, the best method of producing that degree of inflammation re-
quired to cause an adhesion between the tunica vaginalis testis,
and the tunica albuginea, for a radical cure of the hydrocele, II.
80, note, 93. 184. Instruments used in the application of, 185.
Effect of the operation, 186. The method justified against
the objections of Mr. Else, 187.

Skin, sound, as much as possible should always be preserved, II.
145, note,E.; 149, note, E.

Solanum, general effects of this medicine described, II. 65

Spermatic chord, the diseased state of, an absolute prohibition
against the operation of castration in scirrhous cases, II. 139.
How to form a judgment of it, 140.

Spermatic vessels, description of, in reference to the hydrocele,

II. 11.

Spine, description of that curvature of, accompanying a palsy in
the lower limbs, II. 332. Is the first obvious symptom of the
disorder, 333. See Useless State of the Lower Limbs.

Splints, remarks on the use of them for fractured limbs, I. 236.
275.

Strangury, attending abscesses near the rectum, how to be treated.

11.211.

VOL. II. 3 I

430 INDEX.

Suppuration, the act of nature, and always best executed when she
is least disturbed, I. 203.

Surgery, common or practical, deserving of more attention than
is usually paid to it, I. 176. Haste in operations censured,
ibid. Danger of paying too great deference to ancient opinions,
220. Difference between the ancient and modern stated, 300.
Bad effects of erroneous notions of disorders on practice, II. 10.
Brutality of the ancient surgeons, 89, note, 308.

Suture, when proper to be used in a lacerated wound of the scalp,
1.36.

Sutures, of the cranium, no obstruction to the extension of fractures
from one bone to the other, I. 131. The trephine not to be set
upon a suture if it can be avoided, 132. Circumstances in
which such restrictions, are to be disregarded, 140.

Swellings, white. See Scrofulous joints.

Tears, not secreted by the caruncle of the eye, I. 180. Their
origin explained, 182.

Tenesmus, attending inflammatory defluctions on the parts about
the rectum, how to be relieved, II. 213.

Testicles, uncertain time of their descent from the belly, I. 373.
Description of, II. 14. Origin of the disorder called the hy-
drocele, 16. Cases of a hydrocele, where one of the testicles
had never descended into the scrotum, 18. An indurated scirr-
hous testicle distinguished from a hydrocele in the tunica vagi-
talis testis, 55. State of the testicle in the latter case, 58.
The true venereal sarcocele, and the scirrhous testicle, require
different treatment, 59. Operation on the tunica vaginalis, to
obtain a discharge of the water, described, 70. Remarks on
Serjeant Wiseman's caution against the puncture in adults, 72.
Remarks on those applications termed dissolvers of induration,
and removers of obstructions, 88, note. A scirrhous testicle
not produced by a simple hydrocele, 121. Signs of a scirr-
hous testicle, 122. Distinctions between this case and a sim-
ple hydrocele, ibid. Description of the hydrosarcocele, ibid.
Mistakes of ancient writers on this subject, pointed out, 127.
Description of the epididymus, 129. Castration not a danger-
ous operation when performed in time upon a proper subject,
132. But is no cure when a testicle has become cancerous,
ibid. Caution against delays in scirrhous cases, 136. Cir-
cumstances which prohibit the attempt, 138. The state of
the spermatic chord the principal object of consideration, 139.
Castration, how performed, 144. Cases of scirrhous testi-
cles, 151. Their natural situation in the scrotum describ-
ed, 174. The disorders of, ill understood by the ancient sur-
geons, 180,

INDEX. 431

Theodoric, his account of the effects of a contused head, I.
50, note.

Tibia, the nature and important use of that bone, I. 247. Cir-
cumstances attending its fracture, ibid.

Tinctures, spirituous, the application of to a bare bone, tends to
produce exfoliation, I. 38.

Tobacco clysters, the smoke or infusion, efficacy of, in ruptured
cases, I. 411. The infusion, how made, 412, note.

Toes, that kind of mortification beginning in, generally incu-
rable, II. 297. First appearance and symptoms of, 298.
Progress of, ibid. Common method of treatment, ibid. The
bark unsuccessful in stopping it, 299. Efficacy of opium in
this case, 300. Proposed alterations in the chirurgic treatment
of the disorder, 302. The removal of the mortified toes, a
useless and painful operation, 304.

Trephine, the propriety of applying it in certain doubtful cases
inquired into, 1. 61. Especially necessary in gun-shot wounds,
even though the skull should not be broken, 62. See Cases.
Why necessary to be used in simple fractures of the cranium,
97. Ought not to be too long deferred, 98. Reasons why
the ancient surgeons were unwilling to perforate the bone, 107.
Argument against iron handles to these instruments, 112, note.
Why preferable to the trepan, 113, note. Ought to be fixed
immediately over the fracture, 117. The crown or saw should
not be too small, ibid. Circumstances to determine the num-
ber of perforations, ibid. Ought not to be set upon a suture if
it can be conveniently avoided, 132. Application of to a
fractured cranium accompanied with depression, 137. An-
cient restrictions as to parts to which it ought to be applied,
when to be disregarded, 140.

Trocar, curved, method of perforating the os unguis with, I. 211.

Trusses, their operation in rupures explained, I. 322. Steel, may
be worn at all ages, 324. Cautions respecting the use of
them, 325. Danger attending their not fitting truly, 326.
The necessity of using a truss not often taken away by thechirur-
gical operation, 354. When improper in the congenial rup-
ture, 374.

Tumors, produced by contusions of the scalp, danger of mistaking
them for fractures, I. 42. Four kinds of, from injuries to the
scalp, distinguished, 43. See Cases.

Tumors, scirrhous and cancerous, from external violence, their
nature considered, II. 133. Extirpation proper, but not al-
ways effectual, 134, note. Why caustics are generally preferred
to the knife, ibid. note. Why they are really worse, ibid. note.
Rendering the bones soft, 389.

Tunica communis, description of this membrane, II. 31. A hy-

432 INDEX.

drocele in the cells of, how produced, 32. The true nature of
this disorder, not generally understood, ibid. Symptoms of, 33.
Cases of, 34. The encysted hydrocele of, 42. Modes of cure
in infants and in adults, 45. Cases of, 46.

Tunica vaginalis testis, that membrane described, I. 308. Origin
of the scrotal hernia, 309. Hydrocele of, II. 51. Symp-
toms, 52. Cases of, 60. Cases of the dispersion of a con-
firmed hydrocele, 48. The palliative and radical methods
of cure, 69. Operation for discharging the water described,
70. Means for a radical cure, 77. The seton the best me-
thod, 80, note, 173. Cure by caustic, and by incision, 82.
Objections to the caustic, 83. The preference due to incision,
84. Method of operation, 86. Is an object of choice rather
than of necessity, 91. Objections to the tent, 93. And to the
cannula, ibid. Advantages of the seton, ibid. Uses of the
lymph between this membrane and the tunica albuginea, 174.
Consequences of a failure or redundancy of this secretion, 175.
Cure of the hydrocele of, by injection, 191, note, E.

Turner, Dr. Daniel, his mistaken account of the aegylops, I. 1 94,
note. His method of treating the fistula in ano, II. 226, note.

Van Swieten, Baron, his advice to defer amputation in desperate
cases, unadvised and dangerous, I. 266, note.

Varicocele, seldom an original disorder, II 6, 114.

Venereal disease, in old or neglected stages, often produces a se-
paration of a portion of both tables of the cranium, I. 85. This
kind of caries incurable, 86. The continued use of mercury
after the lues is cured, fatal to the constitution, ibid. Some-
times produces a fistula lychrymalis, 191.

Umbilical rupture. See Rupture.

Urethra, caution to be observed in the cure of strictures of, I. 201,
note.

Urine, a retention of, when attending abscesses near the rectum,
how to be treated, II. 211, Efficacy of opium in, ibid, note

Useless state of the lower limbs, further remarks on, II. 347.
Success of the proposed method of cure, 348. Description of
the disease, ibid. Its distinction from palsy, 349. Beginning
and progress in a child, 350. In an adult, 351. True cause
of the disease, a morbid state of the spine, 352. Nature of the
curvature, 353. Arms as well as legs affected, ibid. note. In-
efficacy of various means, and pieces of machinery, 354. Man-
ner in which the bones are affected, 355. The morbid state of
the spine the cause as well of the curvature as of the other
symptoms, 356, and note. Bones affected, not enlarged, but
eroded, 357, note. Method of cure simple, consisting only in
procuring a sufficient drain, 359. Time required for relief

INDEX. 433

very various, 360. Progress of the cure, 36 1 . Deformity re-
maining, 362. Cause of the disease a scrofulous indisposition,
364. Various affections of the spine, 365. Concluding obser-
vations, ibid. The advantages of mechanical assistance in
these cases, 372, note, E.

Ware, Mr. his nail headed style for the fistula lachrymalis, I.

214, note, E.
Wiseman, Mr. Serjeant, his mistaken account of the aegylops, 1 94,

note. Remarks on his account of instruments for extension in

fractured limbs, 221, note.
Words, bad consequence of annexing false ideas to them, I. 252.
Wounds, lacerated, of the scalp, how to be treated, I. 32. By

puncture, 39. Contusions, 42. Of the brain, 142.

THE END.

SQOHDIKg&IL !B(D®I&f

JAMES ^VEBSTEU,

No. 24, South Eighth street, one square from the University,
Philadelphia — publisher of the American Medical Recorder, con-
stantly keeps for sale a general assortment of Medical Books,
among which are, viz.

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